Non Covered Investigational / Experimental 2nd Appeal Letter Free Download


Non Covered Investigational / Experimental 2nd

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Health Symphony Appeal Letter

For Non-Covered Service (Investigational/Experimental)

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 [medical procedure] which we are attempting to get approved by [Health Plan]. [Health Plan] has initially denied payment for this medical procedure stating that it is a non-covered and investigational.

I referred to my policy booklet and there is no specific indication that this is a non-covered or investigational procedure per my health plan’s guidelines. 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.

We have researched this medical procedure and have found that most health plans will pay for this to be performed. It is not considered investigational or experimental by most health plans, but is a required medical treatment that is medically justified. Enclosed you will find a statement of medical necessity from our physician and lab results which will confirm this statement.

[You may consider stating potential medical problems associated with this diagnosis. Explain how you have suffered with your illness and if this procedure is not performed you may need a more significant and costly procedure as a result, but make sure your physician can back this statement.]

To further prove the validity and justification of this medical procedure, I’ve attached 2 articles from respected Medical Journals that support the use of this medical procedure and results obtained. Please review this letter and all of the attached information and reconsider the charges you have previously denied.

Thank you for your time and assistance in this matter.

Sincerely,

[Insured Name]

Enclosures:
A copy of the policy booklet referring to this medical procedure, or lack thereof,
to which a decision made on receiving service was based
Any additional information, such as contact information, phone number of any individual who provided advice or benefit information
A statement of medical necessity from your medical provider
Two Articles from Medical Journals describing the medical procedure and its results.