Ask for the clinical criteria used
A written request for the internal rule, guideline or clinical explanation the plan used to deny your care, so your appeal can answer it point by point. It is a records request, not an appeal.
- Private: nothing leaves this tab
- 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 the denial says not medically necessary, experimental or investigational, or refers to a policy or guideline you have not seen. It works for job-based plans and for Marketplace or individual plans. The plan's notice should have set out the rule or said a copy is free on request; this letter makes that request.
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: Ask for the clinical criteria used Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
[Name of the health plan] denied my claim [Claim or reference number] for [The care or drug that was denied] on [Date on the denial notice], member ID [Member ID]. The stated reason was: [The reason the denial gives]. I am asking for the clinical rules and the explanation behind that decision. This is a request for documents. It is not my appeal.
Please send me, free of charge:
1. A copy of each internal rule, guideline, protocol or similar criterion the plan relied on in making this decision, showing its title, version and date. 2. The scientific or clinical explanation for the decision, applying the terms of the plan to my medical circumstances. 3. If my plan is a group health plan, any statement of plan policy or guidance about the treatment that was denied, for my diagnosis, whether or not the plan relied on it. 4. The name of the plan provision, and the page, that the plan says supports the decision.
The federal claims rule requires a denial notice either to set out the internal rule or guideline relied on, or to say that it was relied on and that a copy is free on request. For a denial based on medical necessity, experimental treatment or a similar limit, the notice must either explain the scientific or clinical judgment, "applying the terms of the plan to the claimant's medical circumstances," or say that the explanation is free on request. If my notice already set out any of these items, please point me to the page.
Please send these promptly, in time for me to use them in my appeal. I want proof of delivery, so please confirm in writing the date you received this request.
Enclosures: 1. Copy of the denial letter
Sincerely, [Your name]
Before you send it
Send it to the address the plan gives for appeals or member records. Look on your denial notice, your member card or the plan's website. If you cannot find one, call the member services number on your card, ask where written requests go, and write down the date, the person's name and any reference number. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the plan's online portal and take a screenshot that shows the date. Keep a copy of the letter.
What to enclose
- Copy of the denial letter
What happens next
- You: send the letter and keep the proof of delivery. Do this in the first weeks, because the answer shapes your appeal.
- Plan: the claims rule says the criteria and explanation are free on request but gives no number of days for this request. Ask in the letter for a reply before your appeal is due, and note the date you sent it.
- You: your appeal deadline keeps running. For most job-based and individual plans you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. A grandfathered individual policy may give less. Check the date on your notice, which controls. If the criteria have not arrived when the deadline gets close, file the appeal and say you asked for them on the date you sent this letter.
- You and your doctor: when the criteria arrive, ask your doctor to compare each requirement with your records. Use the clinician letter on medical necessity if you need help from your doctor's office.
The rule behind this
- 29 CFR 2560.503-1(g)(1)(v), (j)(5) (internal rule and clinical explanation)
- 29 CFR 2560.503-1(m)(8) (what counts as relevant)
- 29 CFR 2590.715-2719(b)(2)(ii)(E) (codes and the standard used)
- 29 CFR 2590.712(d)(1) (mental health and substance use criteria)
- 45 CFR 147.136 (individual and Marketplace plans)
Sources
- 29 CFR 2560.503-1(g)(1)(v), (j)(5) (internal rule and clinical explanation)
- 29 CFR 2560.503-1(m)(8) (what counts as relevant)
- 29 CFR 2590.715-2719(b)(2)(ii)(E) (codes and the standard used)
- 29 CFR 2590.712(d)(1) (mental health and substance use criteria)
- 45 CFR 147.136 (individual and Marketplace plans)
Denial reasons this answers
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.
- Denial reason
Experimental or investigational
The plan says the treatment is unproven or still being tested. That is a medical question, so the appeal rests on evidence. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.