Medical Necessity Appeal Letter and Its Sample

Conflicts between insurance companies and providers go on constantly about medications & procedures for patients. This conflict can result to file a medical necessity appeal letter. It is very important to know how to write such a letter correctly. So, this article will discuss it further.

How to Make a Medical Necessity Appeal Letter

The format of this letter may be tricky. You have to check the policy of the patient to ensure that the procedure is not excluded specifically. Here is the step by step you will need to do:

First of all, you have to state the name of the provider.
Second of all, you need to state the name of the patient.
After that, you should state the date of service.
Then, what you have to write is the procedure in question.
Next, you are required to list the identification, policy, group, & claim numbers of the patient.
Also, you must describe treatment done on the patient.
You also have to describe the treatment result.
To close the letter, you need to note how the treatment helped the patient.

Tips for Creating a Medical Necessity Appeal Letter

There are some tips you should consider and follow to make a well-written letter for a medical necessity appeal.

First, make sure that this letter follows the proper format.
Besides that, good grammar is also required.
Then, ambiguous sentences must be avoided.
In addition, you have to keep it simple, professional, concise, and understandable.
One more, does not forget to sign off the letter to make it legal.

Medical Necessity Appeal Letter Sample

This article provides you an example of a medical necessity appeal letter for your reference.

Dear Ms. Puff,

I’m writing this to address the denial issued on October 20^th, 2020 for our patient Katty. BDC insurance denied the hyalyronan injection into Ms. Katty’s knees. It states that the use of the newer arthritis medication wasn’t needed medically. BDC contends that this shouldn’t be used for Ms. Katty. The newer medication is more expensive. On the other side, the older one would be enough. BDC arthritis specialists appeal this decision respectfully.

I enclosed a history of Ms. Katty’s battle in detail with arthritis & treatments, both in injections and pill form, given to her over the course of the last three years she’s been seeking treatments from our physicians. Other medications never worked for her. That’s why Dr. Pile G. said that the new hyalyroan injection must be tried. For the record, Ms. Katty has experienced a decreased in swelling & an increase in mobility already.

We request that BDC Insurance pay for these injections because these are not excluded in her insurance contract. I can be contacted at (111)-111-1111 or hill@gmail.com. Please call or email me to arrange a meeting or discuss further.

Sincerely,

Hill B.

That is all about a medical necessity appeal letter. If you experience the similar case, you can write such a letter by following the format in the sample above.