Extension of Covered Medical Benefits Appeal Letter Free Download

Extension of Covered Medical Benefits

Download "Extension of Covered Medical Benefits Appeal Letter" Word Document

Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Extension of Covered Medical Benefits

Your name and address


Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment for this medical procedure, stating that it was not medically necessary.

The explanation of benefits I received from [Health Plan] did not adequately describe the reason you denied my claim. In order to properly evaluate your decision, please provide me with the name and credentials of the insurance representative who made the decision to not pay for this medical procedure, an outline of the records reviewed and any other information used to support your decision.

The extended medical office visit performed was both medically necessary and appropriate for the time the physician spent during the procedure and the complexity of the care and treatment provided. I am prepared, with the assistance of my physician, to provide any necessary documentation to support this statement. I have included a statement of medical necessity from the attending physician who is also prepared to provide a rebuttal to your decision once you have provided me with the requested information.

Thank you for your time and consideration.


[Insured’s Name]


Statement of medical necessity from the medical provider