Sample Appeal Letter for Services Denied as 'Not a Covered Benefit'
As someone with cancer or a caregiver for someone with cancer, you have a lot on your
mind without having to worry about payments and insurance. Unfortunately, some insurance
companies may reject claims for certain health services. You do have the option to
In fact, under the Affordable Care Act (ACA), when treatment is denied, you have the
legal right to ask for an internal review and, if this appeal is denied, an independent,
external review. This right applies to plans created after March 23, 2010.
In addition, for plan years or policy years purchased on or after July 1, 2011, the
insurance company must inform you of why your claim was denied, your right to an internal
appeal, your right to an external appeal if the internal review denies your claim,
and the availability of a Consumer Assistance Program (CAP) if your state has one.
Internal reviews must also occur within specific timelines. A review for the denial
of non-urgent care that you have not yet received for example, must occur within
30 days of your review request..
You can use this letter as a model for an efficient, effective appeal letter. You
may also need to enlist the help of a legal professional. Make sure your doctor knows
any issues you have with insurance, as he or she may be able to help you.
[Letter should be addressed to the name of the Appeals Analyst referenced in the Denial
Letter. It should be sent certified mail, return receipt requested. If you are requesting
an expedited review, it should also be faxed or hand-delivered.]
Dear [Appeals Analyst]:
I am writing, on behalf of [name of Plan member if other than yourself], to appeal
the [name of Health Plan] decision to deny [name of service, procedure, or treatment
sought] for [name of Plan member if other than yourself].
It is our understanding that [name of Health Plan] is denying coverage on the basis
that "[cite Health Plan’s language in the denial letter]." [Attach denial letter.]
We believe that [name of service, procedure, or treatment sought] is medically necessary
to treat [name of Plan member if other than yourself]’s medical condition and that
[name of service, procedure, or treatment sought] is a covered plan benefit.
[Name of Health Plan] covers medically necessary services that are not expressly excluded,
which are described in the Evidence of Coverage and which are authorized by the member’s
PCP and in some cases approved by an Authorized Reviewer. [Attach relevant section
from Evidence of Coverage.]
The entire treatment team has recommended that [name of service, procedure, or treatment
sought] is medically necessary. [Attach supporting medical letter.]
Contrary to your letter, [name of service, procedure, or treatment sought] is a covered
service. [Name of service, procedure, or treatment sought] is stated as a covered
benefit in your HMO Member Handbook, is implicitly covered in the Evidence of Coverage,
and is not expressly excluded as a covered service in the Evidence of Coverage. [Quote
from Member Handbook and Evidence of Coverage to establish that the service, procedure,
or treatment is a covered benefit and not expressly excluded.] [Cite your state’s
mandated benefit laws requiring that the health plan provide this coverage.]
[Describe member’s health condition, and why the service, procedure, or treatment
would benefit the member and the consequences if the patient does not receive this
[If the treatment is out-of-network, establish that there are no comparable services
offered within the network.]
[Finally, if you feel they won’t cover the service because of the precedent, ask them
to consider covering it as an extra-contractual benefit, and to pay for the service,
procedure, or treatment out of the Health Plan’s catastrophic payment pool.]
[If the member requires immediate treatment for the condition, request an expedited
hearing – request that they respond within 72 hours of mailing of the letter. Note
that ACA now requires a 72-hour expedited internal review for urgent care. This time
frame is required for plan years or policy years beginning on July 1, 2012.]
[Attach a letter from your treating physician describing the patient’s condition.]
Thank you for your immediate attention to this matter.
cc: [Possible individuals to whom you should consider sending copies of your letter]
[Health Plan Medical Director]
[Medical Group Medical Director]
[Your primary care or treating physician]
[Your state representative if you anticipate further denials]
For more information on the ACA's Right to Appeal process, please go to: http://www.healthcare.gov/law/features/rights/appealing-decisions/index.html.