How to write an appeal letter that works

An appeal letter has one job: to give a reviewer who has never met you everything needed to say yes. It works best when it is short, specific and in order. Start with what you want, give the facts, show why the plan’s decision does not hold up, add your doctor’s support, and ask for a written decision.

What this means

The reviewer on appeal must be someone who was not involved in the first decision and gives it no deference. For a medical judgment, the plan must consult a health care professional with training in the field. The reviewer must consider everything you send. A clear letter helps that person find what matters.

The Arthritis Foundation’s advice for any appeal letter is to label it as an appeal, stick to facts, answer the stated reason, include identifying details and proofread. The Crohn’s & Colitis Foundation adds to state the purpose, include policy and claim numbers and the date of service, and be concise.

What to do

Write the letter in this order. Use the appeal letter builder, or start from the letter that matches your reason (see the list below).

1. Say what you want. “I am appealing the decision dated [date] to deny [service]. I ask the plan to reverse it and approve and pay for this care.” Use the word “appeal”. Include your name, plan, member number, claim number, date of service and provider.
2. Give the facts in order. In a few lines: what the service is, when it was ordered or provided, what the plan decided and when, and the reason it gave. Keep to dates and documents. Leave out opinions about the plan.
3. Show why the plan is wrong, in its own words. Quote the denial reason and the plan’s own definition, criterion or provision, then show where your records meet it. Say what the plan relied on and what it left out. See using your plan’s own words.
4. Add your doctor’s support. Refer to your doctor’s letter and the records. Name them and say what they show. See what a strong letter of medical necessity contains.
5. Ask for what you are entitled to. Ask that someone not involved in the first decision review the appeal. For a medical judgment, ask that a health care professional with training in the field be consulted. Ask for any new evidence or reason the plan will rely on, free of charge and in time to respond; plans that are not grandfathered must provide this. Ask for the reviewer’s name and field.
6. Say what you will do next. For example: “If the plan upholds its denial, I will ask for external review and may complain to the agency that regulates my plan.” Write “external review (also called independent review)” so the plan knows which you mean.
7. Ask for the decision in writing. Ask for a written decision by the date the rules allow, and for the specific reasons if it is upheld.
8. List your enclosures. Number them. Send copies, not originals.
9. Add your statement if you have one. A short personal account of what the condition and the denial have done to you goes in a separate page. See writing your personal statement.

Pick the letter that fits

Start from a matching letter and edit it:

• Medical necessity: appeal: not medically necessary. Experimental: appeal: experimental or investigational.
• Approval before care: prior authorization denied, approved, then denied, step therapy exception and formulary exception.
• Network and emergency care: out of network because no in-network option exists, allowed amount too low and emergency care.
• Coverage and paperwork: not a covered benefit, coding error, filed too late and equipment or supplies.
• Other situations: mental health parity, level of care, ending of ongoing treatment, second-level appeal and expedited appeal.

What to leave out

• Anger and guesses about motives. The Arthritis Foundation lists incomplete, emotional and over-detailed appeals among the reasons appeals fail.
• Medical claims you cannot support. Let your doctor make them.
• Every paper you own. Send what answers the plan’s reason.

The rule

On appeal, a claimant may submit written comments, documents and records, and the plan must consider all of it, including material not submitted or considered in the first decision. See section 2560.503-1(h)(2) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• Your deadline. The plan must give you at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls.
• How fast the plan must answer. The plan must decide within 72 hours for an urgent appeal, 30 days if the care has not happened yet, and 60 days if you are asking it to pay for care you have had. If your plan has two appeal levels, each level has half of the 30 or 60 days, and an urgent appeal is still 72 hours at each level. Check the date on your notice, which controls. For a fast decision, see how to get an expedited appeal.
• Waiting to be perfect. The clock starts when you file under the plan’s procedures, even if the file is incomplete. Send what you have and add more later, with a cover note.
• Medicare, Medicaid and public coverage. These use their own forms and steps. See Medicare and Medicaid and children’s coverage.

What next

• How to assemble and send an appeal packet: enclosures, copies and proof of delivery.
• How to file an internal appeal: where the letter goes and what happens next.
• How external review works: the independent review after a final internal denial.