August 03, 2020
Non-Covered Service

This non-covered service appeal letter template can be tailored to fit your denial. For assistance with a completely researched, focused and custom letter, call the helpline @ 920.664.9407.
Your name and address


Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

I am writing to you in regards to [medical procedure] which we are attempting to get approved by [Health Plan]. [Health Plan] has initially denied payment for this medical procedure stating that it is a non-covered and cosmetic procedure.

I referred to my policy booklet and there is no specific indication that this is a non-covered or cosmetic procedure per my health plan’s guidelines. In order to properly evaluate your decision, please provide me with the name and credentials of the insurance representative who made the decision to not pay for this medical procedure, an outline of the records reviewed and any other information used to support your decision.

We have researched this medical procedure and have found that most health plans will pay for this to be performed. It is not a cosmetic procedure, but a required medical treatment that is medically justified. Enclosed you will find a statement of medical necessity from our physician and lab results which will confirm this statement.

[You may consider stating potential medical problems associated with this diagnosis. But may not be required if your physician has included this in his/her statement of medical necessity.]

Please review this letter and reconsider the charges you have previously denied.  Thank you for your time and assistance in this matter.


[Insured Name]

A copy of the policy booklet referring to this medical procedure, or lack thereof,
to which a decision made on receiving service was based
Any additional information, such as contact information, phone number of any individual who provided advice or benefit information

A statement of medical necessity from your medical provider

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