Insurance Denial Appeal Letter Template (Free)

[Your Name] [Your Address] [City, State, Zip] [Phone] | [Email] [Date] [Insurance Company Name] Appeals Department [Address] Re: Appeal of Denial — [Your Name] Policy Number: [Policy Number] Claim Number: [Claim Number] Date of Service: [Date] Dear Appeals Department, I am writing to formally appeal the denial of [service/procedure] dated [denial date]. The denial stated [exact denial reason from your letter]. I respectfully disagree with this decision and request a full review. MEDICAL NECESSITY [Patient name] has been diagnosed with [diagnosis]. The requested [treatment/procedure] is medically necessary because [explain clinical reasons]. Conservative treatments including [prior treatments] have been attempted without sufficient improvement. According to [clinical guideline source, e.g., "the American College of Physicians guidelines"], [treatment] is indicated for patients with [conditions]. My physician, [doctor name], has confirmed this in the attached letter of medical necessity. CONCLUSION I respectfully request that you reverse the denial and approve coverage for [treatment]. I am happy to provide additional documentation. Please respond within [your plan's timeframe]. Sincerely, [Your Name] [Your Signature] Attachments: - Letter of Medical Necessity from [Doctor Name] - Relevant medical records - Clinical guideline reference