Writing a Letter to Appeal a Medical Claim Denial [Free Sample]

Writing a letter to appeal a medical claim denial is important because it lets the insurance company know that you don’t disagree with the decisions they have handed down.

It also serves as a rebuttal as to why you believe that they should cover the procedure or charges. The important thing is to make sure that the letter contains factual information and is writing in a firm tone.  

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While it is important to be pleasant, an appeal letter needs to be strong and let the insurance company know that you mean business. They need to know that you have no intention of backing down regarding the matter at hand.

Appeal Letter Needs To Include

There are a few things that an appeal letter needs to include. Things like the policy number are helpful to allow them to quickly access the account. They may also need any group numbers or a claim number that has been assigned to the case. Be sure to reiterate their reason for denying the claim. 

Reason For Their Denial

Use this as a basis for the new letter, start with the reason for their denial and then follow this with a brief history of the illness and the need for the procedure or treatment. While this letter may be included in a doctor’s letter that is attached for documentation, it helps to summarize and put things in a quick and readable format.

Was the decision a result of an error on behalf of the insurance company? If you believe this was a mistake, state the correct information that may make all the difference in whether the claim will be approved or denied. It is not uncommon for a coding error to have taken place.

For instance, the insurance company may have you down as receiving one prescription medication when actually it was another one. If they are denying coverage because the medication doesn’t fit the realm of your diagnosis then this could be grounds for a denial. 

Ask For Reconsideration

Make sure to state why you believe they made the wrong decisions. If you need to go out of network to get the services you need, explain yourself well and attach any documentation necessary. The whole purpose of the letter is to ask for reconsideration.

Before drafting an appeal letter, make sure to have property documentation and be ready to answer questions and fill out any packets the insurance company may ask. See sample below for more information on a typical appeal letter.

Sample Letter To Appeal A Medical Claim Denial

May 13, 2022

Virginia Snyder
Blue Cross Blue Shield Insurance Company
9870 Cross Street
New York, NY 10024

Re: Jamie Smith
Medical Coverage –G89078723746 908765678
(Group number/Policy number)

Dear Virginia,

Please accept this letter as an appeal to Blue Cross Blue Shield’s decision to reject coverage for the colonoscopy procedure. It is my understanding based on your notification of refusal of services dated April 20, 2022, that this procedure has been denied because:

A colonoscopy will not be approved more than once in a twelve month period without the presence of cancerous or precancerous cells.

As you know, I was identified as having Irritable Bowel Syndrome on February 20, 2022. Currently Dr. Jonas believes that I will considerably benefit from a second colonoscopy. Please see the enclosed letter from Dr. Jonas that discusses my medical history in more detail.

I believe that you did not have all the necessary information at the time of your initial review. I have also included with this letter, a follow up letter from Dr. Jonas from OSU Medical Center. Dr. Jonas is a specialist in Columbus, Ohio and he is one of the top ranking individuals in his field.

His letter discusses the procedure that is needed in more detail. Also included are my medical records, explaining why this additional procedure is necessary.

Based on the current information, I am requesting that your company reconsider allowing this procedure and cover my colonoscopy as Dr. Jonas outlines in his letter. The treatment is scheduled to take place on June 15, 2022, pending your approval.

Should you require additional information, please do not hesitate to contact me at 570-410-3488. I look forward to hearing from you regarding this matter.


Jamie Smith

Frequently Asked Questions (FAQs)

Q: What is a letter to appeal a medical claim denial? 

Answer: A letter to appeal a medical claim denial is a written correspondence sent by a patient or their representative to an insurance company or healthcare provider to challenge a decision that denies coverage or payment for a medical claim. 

The purpose of the letter is to present additional information, evidence, or arguments to persuade the insurance company or provider to reconsider their decision.

Q: Why would someone need to write a letter to appeal a medical claim denial? 

Answer: There are several reasons why someone might need to write a letter to appeal a medical claim denial. Some common reasons include:

  1. Insufficient documentation: The insurance company may require additional supporting documentation to process the claim, and the letter can provide that information.
  2. Coding errors: If the claim was denied due to coding errors or inaccuracies, the letter can clarify and correct any mistakes.
  3. Medical necessity: The denial might be based on a determination that the treatment or procedure was not medically necessary. The letter can provide evidence to support the medical necessity of the claimed services.
  4. Policy misinterpretation: Sometimes, a claim is denied due to a misinterpretation of the insurance policy. The letter can address any misinterpretations and present arguments based on the policy’s provisions.
  5. Administrative errors: The denial could be a result of administrative errors or misunderstandings. The letter can provide clarification and correct any misconceptions.

Q: What should be included in a letter to appeal a medical claim denial? 

Answer: When writing a letter to appeal a medical claim denial, it’s important to include the following key components:

  1. Heading: Include your name, address, and contact information at the top of the letter.
  2. Date: Write the date when the letter is being sent.
  3. Recipient’s information: Address the letter to the appropriate person or department at the insurance company or healthcare provider.
  4. Introduction: Clearly state that you are writing to appeal a medical claim denial.
  5. Explanation: Provide a detailed explanation of the claim, including the date of service, the billed amount, and the reason for the denial.
  6. Supporting documentation: Attach any relevant medical records, test results, or other supporting documents that strengthen your case.
  7. Medical necessity: Explain why the treatment or procedure was medically necessary and provide any supporting evidence, such as doctor’s notes or expert opinions.
  8. Policy references: Reference specific sections or clauses from the insurance policy that support your claim and challenge the denial decision.
  9. Conclusion: Summarize your argument and request a reconsideration of the denial.
  10. Contact information: Include your phone number and email address in case the recipient needs to reach you for further information.

Q: Can you provide a sample phrase for a letter to appeal a medical claim denial?

Answer: Certainly! Here’s a sample phrase you can use in your letter:

“I am writing this letter to appeal the denial of my medical claim [insert claim reference number] for [describe the treatment or procedure]. I believe that the denial decision was made in error, and I would like to provide additional information and evidence to support my case.”

Q: How should I structure the body of the letter to appeal a medical claim denial?

 Answer: The body of your letter should be well-structured and organized to effectively present your case. Here’s a suggested structure:

  1. Opening paragraph: State the purpose of your letter and briefly explain the denial you are appealing. Use the sample phrase provided earlier to start your letter.

  2. Detailed explanation: In the following paragraphs, provide a comprehensive and detailed explanation of the claim, including the specific treatment or procedure, the date of service, and the billed amount. Clearly outline the reason for the denial as provided by the insurance company or healthcare provider.

  3. Supporting evidence: Present any supporting documentation that reinforces your case. This may include medical records, test results, physician’s notes, referral letters, or any other relevant information. Be sure to reference these documents in your letter and attach them as separate enclosures.

  4. Medical necessity argument: Dedicate a section to explain why the treatment or procedure in question was medically necessary. Provide a clear and compelling argument, citing expert opinions, medical guidelines, or any other evidence that supports the necessity of the claimed services.

  5. Policy references: Refer to specific sections or clauses in your insurance policy that support your claim. Highlight any provisions that indicate coverage for the treatment or procedure. Explain why the denial decision contradicts the policy’s terms and provide a persuasive argument based on those terms.

  6. Conclusion: Summarize your key points and restate your request for a reconsideration of the denial. Emphasize your desire for a fair and thorough review of your claim. Express your willingness to provide further information or answer any questions that may assist in the reconsideration process.

  7. Closing: Thank the reader for their time and consideration. Provide your contact information once again, including your phone number and email address, so they can easily reach you if needed.

Q: Is there anything else I should consider when writing a letter to appeal a medical claim denial? 

Answer: Yes, here are a few additional points to consider:

  1. Be concise: While it’s important to provide all the necessary details, try to keep your letter concise and focused. Stick to the relevant facts and arguments to make your case effectively.

  2. Use a professional and respectful tone: Maintain a professional and respectful tone throughout the letter. Avoid using aggressive or confrontational language, as it may hinder the chances of a successful appeal.

  3. Follow instructions and deadlines: Pay attention to any specific instructions or deadlines provided by the insurance company or healthcare provider. Adhere to their guidelines for filing an appeal, including the required format or submission method.

  4. Keep copies of all correspondence: Make copies of your appeal letter, supporting documents, and any subsequent communication with the insurance company or healthcare provider. This will help you keep track of your efforts and provide a record of your appeal process.

  5. Consider seeking assistance: If you’re unsure about the appeal process or need additional support, consider seeking assistance from a healthcare advocate, patient advocacy organization, or legal professional experienced in medical claim appeals.

Remember, the specific details and language used in your letter will depend on your unique situation and the requirements of your insurance company or healthcare provider