Sample: Written Medical Necessity Appeal

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To: XYA Health Plan
Appeals

From: Jane Smith, DPM
NPI number:

Re: Appeal of claims denial: Joe Jones
XYA policy number: 12345; XYA group number: 12345
Claim number: 1234
Date of service: Use date of service for the patient.

Date: Date Letter is Written

This memo serves as an appeal of the above referenced claim, which XYA denied as “not medically necessary/experimental.” I have included the following supporting documentation which, demonstrates that (procedure X) I performed on Mr. Jones was medically necessary, according to the medical necessity definition in my provider contract:

• Mr. Jones medical record
• Mr. Jones lab test results
• Mr. Jones surgical report
• Mr. Jones post-operative report

• The medical record shows that Mr. Jones was diagnosed with Y.
• I determined that procedure X was appropriate because _______. This was supported by ______________.
• Performing procedure X on a patient with Mr. Jones’ current condition and medical history is the most effective approach, and in fact, prevents more costly treatment in the future. I have included scientific articles supporting this approach.
• The post-operative report on Mr. Jones reflects that the surgery successfully resolved this condition. Failing to perform the procedure would have almost certainly resulted in great costs in the future because_______________.