How to Write a Letter of Appeal to an Insurance Company

Be sure to write a clear and simple letter that includes:

• All relevant clinical information regarding your health and medication history, including any medical records documenting your care
• Information on other drugs or drug dosages you have tried or considered but were or would have been ineffective or harmful
• Any adverse reactions or side effects you’ve experienced with similar medications (over-the-counter or prescription drugs)
• Prior use of generic equivalents that were ineffective
  

If you need to prove “medical necessity,” ask your doctor to write a letter that addresses the following (if applicable in your case):

• A summary of your diagnosis and why the drug was prescribed
• The diagnosis code(s) (ICD-10-CM). ICD-10 codes are used by physicians and healthcare providers to classify medical diagnoses, symptoms, and procedures. They help insurance companies understand what care was provided to you and why it was necessary.
• The severity of your condition
• Any prior treatment(s), including duration of each and your response to it
• The clinical rationale for prescribing this drug: whether it will prevent the onset of an illness; reduce or relieve the physical, mental, or developmental effects of an illness; and/or will help you perform daily activities, such as dressing, eating, and showering
• An explanation of why your plan’s preferred formulary drugs are not appropriate for you
  

Even if you don’t need to prove “medical necessity,” ask your doctor to provide supporting information:

• About your health, including pathology reports, clinical notes or medical records, diagnostic testing results, or scans that show progressive disease
• About the drug, including prescribing information, relevant peer-reviewed articles, clinical practice guidelines, clinical trial data, or FDA approval letter for the drug
  

One last piece of advice: Follow up and be persistent, while also remaining polite and as calm as possible. If your first request is denied, go to the next level. Use everything in your arsenal to make your case, including national organizations that support patients with your medical condition, social media, your local television station’s consumer watchdog advocate—and even visiting the denials office in person. Remember, insurers anticipate most patients will go away. Do not quietly or easily accept no as an answer.

Jody McCaffrey is an award-winning freelance health and wellness writer based in New Jersey.