Appeal: level of care
Asks your plan to approve the level or setting of care your clinician recommended, such as a hospital stay or residential program, instead of a lower one.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan approved a lower level or different setting of care than your clinician recommended, for example outpatient instead of a hospital stay, or a shorter stay than advised. Get your clinician's notes first.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: level of care Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number] under [Name of the health plan], member ID [Member ID]. The plan did not approve [The level or setting of care your clinician recommended] for [The care or drug that was denied] at [Doctor, hospital or pharmacy]. What the plan approved instead, if anything, was: [What the plan approved instead, if anything] I ask you to reverse that decision and approve the level of care my treating clinician recommended.
The level and setting of care are medical judgments. My treating clinician, [Your treating doctor or clinician's name and role], recommended [The level or setting of care your clinician recommended] because: [Why the lower level of care is not enough]
The plan gave this reason: [The reason the plan gave] The plan named these criteria: [The criteria the plan named] I ask the plan to explain which criterion it says my records do not meet, what in my records supports a lower level of care, and how it weighed what has already been tried at lower levels.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Because the denial rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization, which can review decisions about level of care and health care setting, and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. Notes or letter from my treating clinician 3. Relevant records, including what was tried at lower levels of care 4. Any criteria the plan sent me
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- Notes or letter from my treating clinician
- Relevant records, including what was tried at lower levels of care
- Any criteria the plan sent me
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls. If waiting could seriously harm you, ask for an expedited appeal, which must be decided within 72 hours.
- Ask your clinician to write a letter that says what level of care is needed and what could happen at a lower level, and send it to the plan if you have not already.
- If the plan says no again, ask for external review. After a final internal denial about an admission, available care or a continued stay, expedited external review is available while you have not been discharged. For most job-based and individual plans you have at least four months to ask for standard external review. Check the date on your notice, which controls.
- You can also complain to the agency that oversees your plan. A complaint does not stop your appeal deadline, so file the appeal first.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Level of care
Your plan agrees you need treatment but says a less intensive setting would do. For example, outpatient care instead of residential care, or a lower-intensity program instead of a hospital stay.
- Denial reason
Wrong site of service
Your plan will pay for the service but not where your doctor wants it done, such as a hospital outpatient department instead of a doctor's office. Whether the setting is safe for you is a medical judgment you can challenge.
- Denial reason
Observation instead of inpatient
The hospital kept you but billed the stay as outpatient observation. If you were formally admitted and then switched, you can appeal in two cases, and must ask before you leave to keep billing protection. If never admitted, this right does not apply.