Medication and prescription appeal letter template

[Date]

[Your full name]
[Your address]
[Your phone]  ·  [Your email]

[Insurer name], Appeals Department
[Appeals address from your denial letter]

Re: Appeal of medication and prescription denial
Member: [Patient name]  ·  Member ID: [Member ID]  ·  Group: [Group #]
Claim #: [Claim #]  ·  Date(s) of service: [Date of service]
Denial date: [Denial date]  ·  Denial/reason code: [Code]

To the Appeals Department:

I am formally appealing [Insurer]'s [denial date] denial of [service or medication]. I request that the denial be overturned and the medication and prescription approved.

1. The denial. [Insurer] denied this medication and prescription stating, verbatim: "[paste the exact denial language from your letter]."

2. Why the denial is incorrect. [State, in one or two sentences, why the service is medically necessary for your condition, and answer the specific reason the plan gave.]

3. The controlling standard. [See the standard for this denial type below, then cite it here.]

4. The evidence. I am attaching:
   - A letter of medical necessity from my treating provider addressing each clinical criterion;
   - [Your supporting records: see the document checklist below];
   - The clinical guidelines and records that support coverage.

5. My request. I request a full reversal of this denial and approval of [service or medication] within the timeframe required by law. If the denial is upheld, please provide in writing the specific clinical criteria used, the credentials of the reviewing clinician, and instructions for independent external review. Under 29 C.F.R. 2560.503-1 (employer plans) or 45 C.F.R. 147.136 (ACA plans), please also provide all documents and records relevant to this claim.

Sincerely,
[Patient name / authorized representative]