Prior Authorization Appeal Letter Template (Free)

Dear Medical Review Team,

I am writing to formally appeal the denial of prior authorization for [medication name and dosage] OR [treatment/procedure] for my patient, [Patient Full Name]. This [medication/treatment] is medically necessary for the treatment of [diagnosis] and is supported by clinical evidence, specialty society guidelines, and FDA approvals.

I. PATIENT CLINICAL SUMMARY

Primary Diagnosis:

• [Condition name] (ICD-10 code: [X##.#])
• Date of diagnosis: [Date]
• Disease severity: [Mild/Moderate/Severe with supporting data]
• Key clinical findings: [Lab values, imaging results, symptoms]

Relevant Comorbidities:

• [Comorbidity 1] (ICD-10: [X##.#])
• [Comorbidity 2] (ICD-10: [X##.#])
• [Additional conditions that strengthen medical necessity]

Current Medications:

• [Current medications and dosages]
• [Note any drug interactions or contraindications with denied medication]

II. PRIOR TREATMENT HISTORY

The patient has attempted the following treatments with inadequate results or intolerable side effects:

Medication/Treatment	Dosage/Duration	Outcome/Reason for Discontinuation
[Medication 1]	[Dose, frequency, duration - e.g., "500mg BID x 6 months"]	[e.g., "Discontinued due to gastrointestinal intolerance; inadequate disease control (HbA1c remained >8.5%)"]
[Medication 2]	[Dose, duration]	[Specific outcome - side effects, lack of efficacy, contraindications]
[Medication 3]	[Dose, duration]	[Outcome with objective data when possible]

Supporting documentation of these trials is included in the attached medical records.

III. MEDICAL NECESSITY FOR REQUESTED [MEDICATION/TREATMENT]

[Medication/Treatment name] is medically necessary for this patient based on the following clinical rationale:

1. Disease Severity and Treatment Goals:

   [Explain patient's current condition severity with objective data. Example: "The patient's HbA1c is currently 9.2%, well above the target of <7% recommended by the American Diabetes Association. Continued hyperglycemia places the patient at high risk for microvascular and macrovascular complications."]

2. Failure of Alternative Treatments:

   [Reference prior treatment table above. Example: "As documented above, the patient has completed adequate trials of metformin and sulfonylureas without achieving glycemic control, demonstrating inadequate response to first-line therapies."]

3. Contraindications to Alternative Therapies:

   [List any medical reasons alternative treatments can't be used. Example: "The patient has stage 3 chronic kidney disease (eGFR 42 mL/min), contraindicating metformin use at higher doses. Additionally, documented hypoglycemic episodes on sulfonylureas make this class inappropriate for continued use."]

4. Unique Benefits of Requested Treatment:

   [Explain why THIS specific treatment is appropriate. Example: "Semaglutide (Ozempic) provides both glycemic control and cardiovascular risk reduction, as demonstrated in the SUSTAIN-6 trial. Given the patient's established cardiovascular disease (prior MI in 2020), a GLP-1 receptor agonist with proven CV benefits is the appropriate therapeutic choice."]

IV. CLINICAL EVIDENCE AND GUIDELINE SUPPORT

FDA Approval Status:

[Medication] is FDA-approved for [indication]. The patient's diagnosis of [condition] falls within this approved indication.

OR (if off-label):

While [medication] is FDA-approved for [approved indication], its use for [patient's condition] is supported by [clinical evidence, peer-reviewed studies, and specialty society guidelines as described below].

Specialty Society Clinical Guidelines:

• [Specialty Society Name] ([Year] Guidelines):

  "[Quote relevant guideline recommendation]"

  Citation: [Society Name]. [Guideline Title]. [Publication]. [Year];[volume]:[pages].

• [Additional Guideline 2]:

  [Recommendation quote and citation]

Peer-Reviewed Clinical Evidence:

• [Study Name/Trial]: [Brief description of study showing efficacy/safety for patient's condition]

  Citation: [Authors]. [Title]. [Journal]. [Year];[volume]:[pages].

• [Additional Study]: [Description and citation]

V. RESPONSE TO DENIAL REASON: "[SPECIFIC DENIAL REASON]"

[This section should directly address the specific reason given in your denial letter. See examples below for common denial reasons.]

For "Step Therapy Required" Denials:

The patient has completed step therapy requirements as documented in Section II above. [List specific medications tried and failed]. Additionally, [any contraindications making further step therapy inappropriate]. Based on documented treatment failures and medical contraindications, step therapy override is medically justified.

For "Not Medically Necessary" Denials:

Medical necessity is clearly established by: (1) disease severity [cite specific metrics], (2) failure of alternative treatments [reference prior treatment history], (3) clinical guideline support [cite specialty society recommendations], and (4) unique therapeutic benefits addressing patient's specific clinical needs [describe]. This treatment represents the standard of care for patients with [condition] who have failed [prior treatments].

For "Experimental/Investigational" Denials:

[Medication/Treatment] is FDA-approved for [indication], demonstrating it is not experimental but rather an established therapeutic option. Clinical guidelines from [specialty societies] recommend this treatment for [condition], further confirming its status as standard of care rather than investigational therapy.

For "Off-Label Use" Denials:

While the FDA-approved indication for [medication] is [approved use], off-label prescribing for [patient's condition] is supported by [clinical evidence, guidelines, peer-reviewed studies]. Off-label use is recognized as appropriate medical practice when supported by clinical evidence, as is the case here. [Cite specific guidelines or studies supporting off-label use].

VI. HEALTH RISKS OF TREATMENT DELAY

Delaying treatment with [medication/procedure] poses the following risks to the patient's health:

• [Specific risk 1 - e.g., "Continued hyperglycemia increases risk of diabetic complications including retinopathy, nephropathy, and neuropathy"]
• [Specific risk 2 - e.g., "Uncontrolled disease progression may result in irreversible organ damage"]
• [Specific risk 3 - e.g., "Severe pain and functional impairment continue to significantly impact quality of life and ability to work"]

[If applicable, add urgency statement for 72-hour review: "Based on the serious health risks described above, I am requesting expedited review of this appeal within 72 hours under federal regulations for urgent medical needs."]

VII. CONCLUSION AND REQUEST

Based on the clinical evidence presented, specialty society guideline support, documented failure of alternative therapies, and serious health risks of treatment delay, I respectfully request that you overturn the prior authorization denial and approve coverage for [medication with dosage] OR [treatment/procedure] for [Patient Name].

This treatment represents the appropriate standard of care for this patient's condition and is medically necessary to prevent serious health consequences.

I am available for peer-to-peer review or to provide any additional medical information needed to support this appeal. Please contact me at [phone number] or [email address] with any questions.

Sincerely,

[Doctor Signature]

[Doctor Printed Name, MD/DO]
[Specialty - e.g., "Board Certified Endocrinologist"]
[Medical License Number]
[DEA Number - if prescribing controlled substance]
[Phone Number]
[Email Address]

Enclosures:

• Copy of prior authorization denial letter
• Medical records documenting diagnosis and treatment history
• Laboratory results [specify: HbA1c, lipid panel, etc.]
• Imaging studies [if relevant]
• Clinical guideline excerpts [specialty society recommendations]
• Peer-reviewed study references [if applicable]
• Documentation of prior medication trials and outcomes

cc: Patient