Lack of Medical Necessity Maternity Appeal Letter Free Download

Lack of Medical Necessity Maternity

Download "Lack of Medical Necessity Maternity Appeal Letter" Word Document

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Health Symphony Appeal Letter

For Lack of Medical Necessity for Maternity

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 the length of stay was not pre-authorized.

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.

Additionally, according to the Department of Insurance for the State of Idaho, it indicates that “{include relevant sections of the state policy regarding maternity benefits}.”

I have included a copy of this regulation and 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

You must confirm with the Department of Insurance that this regulation would apply in your situation before including this statement in your appeal