3 Proven Templates for Dental Insurance Appeals

Below are three templates for different scenarios you might encounter. These templates serve as a starting point; personalize them with specific details about your situation.

Template 1: Claim Denial Appeal



[Your Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Insurance Company Name]
[Claims Appeal Department]
[Insurance Company Address]
[City, State, ZIP Code]

Subject: Appeal for Claim Denial – [Claim Number]

Dear Claims Appeal Department,


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I am writing to formally appeal the denial of my dental claim [claim number] dated [date of denial]. The treatment, which involved [specific treatment details], was deemed necessary by my dentist, [Dentist’s Name], due to [brief explanation of dental condition and why treatment was necessary].

Enclosed are copies of my dental records, a letter from [Dentist’s Name] detailing the necessity of the treatment, and the specific denial reason cited by [Insurance Company Name]. According to the denial notice, the claim was rejected based on [insert reason for denial as provided by the insurance company]. 

However, as detailed in the attached dentist’s letter, this treatment is not [cosmetic/experimental/not covered for any other reason specified by the insurance], but a medically necessary procedure due to [insert detailed reason].

I respectfully request a comprehensive review of my claim and the attached documentation. I believe, upon review, you will find the treatment falls within the scope of my coverage benefits.

Thank you for your attention to this matter. I look forward to your prompt response.

Sincerely,

[Your Signature (if sending by mail)]
[Your Printed Name]

Template 2: Pre-Authorization Request Denial Appeal

[Your Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Insurance Company Name]
[Pre-Authorization Appeal Department]
[Insurance Company Address]
[City, State, ZIP Code]

Subject: Appeal for Pre-Authorization Denial – [Pre-Authorization Number]

Dear Pre-Authorization Appeal Department,

I am writing to appeal the denial of a pre-authorization request for [specific treatment] initially submitted on [date]. This request was denied on [date of denial], as detailed in the correspondence from [Insurance Company Name]. The reason given for this denial was [reason for denial].

Included with this letter, you will find detailed information from my dental care provider, [Dentist’s Name], including a comprehensive treatment plan, x-rays, and a narrative explaining the necessity of the proposed treatment. 

Despite the denial reason, these documents will demonstrate the medical necessity and urgency of the treatment due to [specific dental condition].

I kindly request a reevaluation of my pre-authorization request based on the additional information provided. This treatment is critical for preventing further dental complications and aligns with the coverage provided under my policy.

Thank you for reconsidering my request. I am eager for a resolution that will allow me to proceed with the necessary dental care.

Sincerely,

[Your Signature (if sending by mail)]
[Your Printed Name]

Template 3: Request for Increased Coverage Amount Appeal

[Your Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Insurance Company Name]
[Coverage Adjustment Appeal Department]
[Insurance Company Address]
[City, State, ZIP Code]

Subject: Appeal for Coverage Adjustment – [Policy Number]

Dear Coverage Adjustment Appeal Department,

I am writing to request a review and adjustment of the coverage for my recent dental treatment under policy number [policy number]. The treatment, performed on [date of treatment], included [list of procedures] and was essential for treating [name of dental condition].

The current coverage as applied to my claim, detailed in the explanation of benefits dated [date], significantly limits the coverage for procedures that are crucial for my dental health. This limitation has resulted in a substantial out-of-pocket expense, which I believe does not reflect the intention of my dental benefits package.

Enclosed are my dental records, a detailed treatment plan from my dentist, [Dentist’s Name], and a personal statement regarding the impact of this dental condition on my overall health. These documents support the necessity and appropriateness of the treatment.

I respectfully request a reevaluation of the coverage amount for my recent dental treatment. I believe that, given the documentation and explanations provided, the treatment merits a coverage adjustment.

Thank you for your consideration of my appeal. I am hopeful for a favorable response that acknowledges the necessity of comprehensive dental care under my policy.

Sincerely,

[Your Signature (if sending by mail)]
[Your Printed Name]


For each of these templates, ensure you attach all relevant documentation, including medical records, detailed treatment plans, letters from your healthcare provider, and any prior correspondence with the insurance company. 

Tailor each letter to fit your specific situation, and keep copies of everything you send for your records.

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