October 02, 2014
Medical Appeal Letter: 
Not Medically Necessary

This not medically necessary medical appeal letter template can be tailored to fit your denial. 

Your name and address 
 
Date
 
Address of Claims review department 
RE: Name of Insured:
Plan ID #:
Claim #: 
 
Dear Claims Review Department:
 
I am writing you this medical appeal in regards to a claim submitted by [Medical Provider] for [patient].  The charges were rendered on [Date] and totaled [Claim dollar total].  [Health Plan] has denied payment for this medical procedure, stating that it was not medically necessary.
 
The explanation of benefits I received from [Health Plan] did not adequately describe the reason you denied my claim.  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.  
 
Additionally, I have included a statement of medical necessity from the attending physician who is also prepared to provide a rebuttal to your decision once you have provided me with the requested information.
 
Thank you for your time and consideration.
 
Sincerely, 
[Insured’s Name]
 
Enclosures:
Statement of medical necessity from the medical provider




          
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