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Lack of Medical Necessity

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Health Symphony Appeal Letter

For Lack of Medical Necessity

Your name and address

Date

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.

Option 1: 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.

Option 2: It is our understanding that [Health Plan] is denying coverage on the basis of [indicate specific policy language used to deny the claim.] However, we believe that [procedure/treatment sought] is medically necessary to treat [patient name] and that this [service/treatment] is a covered benefit of the plan.

Additionally, 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.

Sincerely,

[Insured’s Name]

Enclosures:

Statement of medical necessity from the medical provider