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Medical Necessity Appeal Letter Sample & Templates

See real appeal letters that overturned medical necessity denials—with annotations explaining why they worked.

Sample Appeal Letter: Cancer Treatment Denial

This letter overturned a $247,000 denial for targeted cancer therapy in 11 days:

[Your Name]
[Your Address]
[City, State ZIP]
[Phone Number]
[Email]

[Date]

[Insurance Company Name]
Appeals Department
[Insurance Address]

RE: Appeal of Denial for Claim #[CLAIM NUMBER]
Patient: [Your Name]
Policy #: [POLICY NUMBER]
Denied Treatment: Palbociclib (Ibrance) + Letrozole

Dear Appeals Committee,

I am writing to appeal the denial of coverage for Palbociclib (Ibrance) in combination with Letrozole for my Stage 3 HR+/HER2- metastatic breast cancer, as outlined in my oncologist Dr. Sarah Johnson's treatment plan dated [DATE].

Why this works: Opens with specific denial details: claim number, exact treatment, diagnosis codes. Makes it easy for reviewers to locate your file immediately.

Your denial letter states this treatment is "not medically necessary" under Section 3.2 of my policy. I respectfully disagree and provide the following evidence demonstrating medical necessity:

Why this works: Directly quotes the denial reason and policy section. Shows you understand their argument and are addressing it head-on.

1. Clinical Appropriateness

My diagnosis of HR+/HER2- metastatic breast cancer (ICD-10: C50.919, Z85.3) makes me an ideal candidate for this FDA-approved combination therapy. According to the National Comprehensive Cancer Network (NCCN) Guidelines Version 4.2023, Palbociclib + Letrozole is a Category 1 recommendation (highest evidence level) for first-line treatment of HR+ metastatic breast cancer.

My policy specifically covers "medically necessary cancer treatments recommended by clinical practice guidelines" (Policy Section 5.8). NCCN guidelines are recognized industry-standard and meet this criteria.

Why this works: Cites authoritative clinical guidelines (NCCN) with specific version and category rating. Then immediately connects to policy language requiring coverage for guideline-based treatments. Creates airtight logical connection.

2. Evidence-Based Treatment

Multiple peer-reviewed studies demonstrate the medical necessity of this combination:

PALOMA-2 Trial (NEJM 2016): Showed 24.8-month progression-free survival vs. 14.5 months for letrozole alone (HR 0.58, p<0.001)
PALOMA-3 Trial (Lancet Oncology 2018): Confirmed sustained benefit in real-world settings
FDA Approval (February 2015): Approved specifically for my diagnosis with this combination

These studies collectively involved over 1,200 patients and represent the gold standard of evidence for HR+ metastatic breast cancer treatment.

Why this works: Provides specific research with publication dates, trial names, and statistical results. Shows treatment isn't experimental—it's evidence-based standard of care. Includes FDA approval as regulatory validation.

3. Medical Necessity for My Specific Case

Alternative treatments have failed or are contraindicated:

First-line chemotherapy (AC-T protocol): Completed 6 cycles (March-August 2023) with disease progression
Letrozole monotherapy: Tried for 4 months (Sept-Dec 2023) with continued tumor growth confirmed by PET scan
Clinical trial enrollment: No suitable trials available within 200 miles per NCI database

Dr. Johnson's letter (attached) details why this combination is my best remaining option before considering more toxic chemotherapy regimens. Delaying this treatment risks disease progression that could eliminate future treatment options.

Why this works: Documents failed alternatives with specific dates and outcomes. Proves this isn't "jumping ahead" in the treatment ladder—you've exhausted cheaper options. References attached doctor's letter for clinical authority.

4. Not Experimental

Your denial suggests this treatment is experimental. However:

FDA-approved since 2015 (9 years of real-world use)
Included in NCCN Category 1 guidelines (highest evidence)
Covered by Medicare under NCD 110.8
Standard of care at major cancer centers (MD Anderson, Mayo Clinic, Sloan Kettering)

Per your policy's definition (Section 2.14), experimental treatments are "not FDA-approved or lacking clinical evidence." This treatment has both.

Why this works: Directly counters "experimental" objection with regulatory and clinical proof. Quotes policy's own definition of experimental and shows treatment doesn't meet it. Uses Medicare coverage as validation (insurers often follow Medicare).

5. No Equally Effective Alternative

Your denial suggests using letrozole alone. Clinical evidence shows this is inadequate:

10.3-month difference in progression-free survival (PALOMA-2)
42% reduction in disease progression risk with combination vs. monotherapy
I already failed letrozole monotherapy (PET scans show progression)

The cost difference between monotherapy and combination is outweighed by the clinical benefit and the cost of treating disease progression.

Why this works: Addresses insurer's likely cost motivation ("use cheaper option") by showing cheaper option is clinically inferior with data. Also notes you already tried and failed the cheaper option—critical evidence.

Conclusion

This treatment meets all five criteria for medical necessity as defined in Section 3.2 of my policy:

✓ Appropriate: NCCN Category 1 for my diagnosis
✓ Evidence-based: Supported by peer-reviewed trials and FDA approval
✓ Essential: After failed alternatives, this is standard of care
✓ Not experimental: 9 years of FDA approval and clinical use
✓ No cheaper equivalent: Monotherapy failed; combination is necessary

I respectfully request approval of Palbociclib + Letrozole as medically necessary treatment under my policy. Please respond within 15 business days as required under state regulations.

I have enclosed the following supporting documentation:

Dr. Johnson's Letter of Medical Necessity
Medical records (diagnosis, treatment history, PET scans)
NCCN Guidelines excerpt
PALOMA-2 and PALOMA-3 trial summaries
FDA approval letter
Policy sections referenced

Thank you for your prompt attention to this matter.

Sincerely,

[Your Signature]
[Your Printed Name]

Why this works: Provides clear summary checklist showing how treatment meets EVERY policy criterion. Makes it easy for reviewer to approve. Ends with specific request, timeline expectation, and list of enclosed evidence for quick reference.

Generate Your Custom Appeal Letter in 5 Minutes

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Key Elements Every Appeal Letter Needs

Opening Section

Claim number and policy number
Specific denied treatment/service
Date of denial letter
Clear statement: "I am appealing..."

Body (5 Parts)

Clinical Appropriateness: Diagnosis + guidelines recommending treatment
Evidence Base: Research studies, FDA approval, clinical trials
Personal Medical Necessity: Your history, failed alternatives, unique factors
Not Experimental: Counter "experimental" claims with approval status
No Cheaper Alternative: Why less expensive options won't work for you

Closing

Summary checklist of criteria met
Specific request for approval
Timeline expectation
List of enclosed documents
Professional signature

More Sample Templates by Treatment Type

Template: Physical Therapy Denial

Use when insurer limits therapy sessions or denies extended treatment

Key Points to Include:

Physical therapist's treatment plan with specific goals and timeline
Progress notes showing measurable improvement (ROM, strength, function)
Clinical guidelines for your condition recommending X sessions
Why stopping therapy now would result in regression/reinjury
Comparative cost: therapy vs. surgery or long-term disability

Cite: APTA (American Physical Therapy Association) practice guidelines for your diagnosis

Template: Brand-Name Medication Denial

Use when insurer requires generic but it's not suitable for you

Key Points to Include:

Doctor's statement that brand-name is medically necessary
Documentation of failed generic trial (dates, dosage, side effects)
Specific reasons generic won't work: different inactive ingredients causing allergies, different release mechanism affecting efficacy
FDA "therapeutic equivalence" rating (if generic is rated less than brand)
Pharmacy records showing attempted generic fills

Quote Policy: "Formulary exceptions for documented medical necessity" (most policies have this)

Template: Mental Health Treatment Denial

Use when insurer limits therapy sessions or denies specific treatment types

Key Points to Include:

Therapist/psychiatrist letter with diagnosis (DSM-5 codes) and treatment plan
Evidence-based treatment guidelines (APA for psychology, AMA for psychiatry)
Mental Health Parity Act citation (federal law requiring equal coverage)
Progress notes showing clinical need for continued treatment
Risks of interrupting treatment (relapse, hospitalization)

Legal Hook: Mental Health Parity and Addiction Equity Act requires insurers to cover mental health equivalent to physical health

Not Sure What to Write?

Our AI generates appeal letters customized for your specific denial—with all the right citations and policy references.

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Common Mistakes to Avoid

❌ Don't do this:

Emotional appeals only: "I'm suffering and need this" without clinical evidence
Vague requests: "Please reconsider" instead of "I request approval of [specific treatment]"
No research citations: Just saying "my doctor says I need it"
Ignoring the denial reason: Not addressing why insurer said no
Missing policy references: Not showing how you meet THEIR criteria
No supporting documents: Letter alone without medical records/research

How to Submit Your Appeal

Send via certified mail with return receipt: Creates paper trail and proof of delivery
Keep copies: Save the letter, all attachments, and mailing receipt
Note the deadline: Insurers typically have 30-60 days to respond
Follow up: Call every 7-10 days to check status
Document everything: Log all calls with dates, representative names, and what was discussed

Next Steps If Denied Again

If your internal appeal is denied, you have additional rights:

External review: Independent medical expert reviews your case (often overturns 40-50% of denials)
State insurance commissioner complaint: File formal complaint with your state regulator
Department of Labor complaint: For employer plans under ERISA

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