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Insurance appeal letter
A skeleton for a member-written appeal of a coverage denial. Fill the square brackets. Your prescriber's letter of medical necessity is a separate document; this letter carries it. Deadlines quoted are the federal ones described on HealthCare.gov; your plan's notice states the ones that apply to you.
[Your name] [Address] [Phone and email] [Date]
[Plan name], Appeals Department [Address from the denial letter]
Re: Request for internal appeal. Member: [name], member ID [number], group [number]. Claim or reference number: [number]. Medication: [name and strength as prescribed]. Denial dated [date].
I am writing to appeal the denial of coverage for [medication], prescribed by [prescriber name, credentials] on [date]. The denial letter gives the reason as: "[quote the reason exactly as written]". I am filing within the 180-day window stated in your notice and request a full review of the enclosed records.
[One paragraph of clinical facts in plain language: diagnosis, current BMI and the date measured, weight-related conditions, how long they have been treated, what has been tried before and with what result. Use the numbers from the chart; do not estimate.]
[One paragraph answering the stated denial reason directly. If the plan says documentation was missing, name the enclosed document that supplies it. If the plan says criteria were not met, point to the specific criterion and the record that meets it. If the plan cites a formulary exclusion, say so and ask for the exception process.]
Enclosed: [1] the denial letter; [2] a letter of medical necessity from [prescriber]; [3] chart notes dated [dates] with height, weight and BMI; [4] records of prior weight-management attempts; [5] lab results dated [dates]; [6] the plan's PA criteria with the relevant sections marked.
[If applicable] Because a delay would seriously jeopardise my health for the following reason, [reason], I request an expedited appeal.
Please confirm receipt in writing and send the decision, with the clinical rationale and the reviewer's credentials, to the address above. If this appeal is denied, I intend to request an independent external review, which federal rules allow me to file within 4 months of the final denial notice and which must be decided within 45 days, or 72 hours when expedited.
Sincerely, [Signature] [Printed name]
Deadlines from HealthCare.gov
- Internal appeal
- File within 180 days of the denial notice
- Plan decision
- 30 days (service not yet received), 60 days (already received), within 4 business days when urgent
- External review
- Request within 4 months of the final internal denial; decided within 45 days, 72 hours if expedited
An appeal letter is not an essay. It is a document that names the denial, quotes the reason, answers it, and lists what is enclosed. Reviewers read hundreds; the ones that work are the ones where the answer to the stated reason is in the second paragraph and the evidence is behind it in the order the letter mentions it. This template is that structure with square brackets where your facts go.
The two rights the letter relies on
Under the Affordable Care Act, as HealthCare.gov describes it, you have the right to an internal appeal, filed within 180 days of the denial notice, which the plan must decide within 30 days for a service you have not yet received, 60 days for one you have, and as quickly as your condition requires and at least within 4 business days when urgent. If the internal appeal fails, you have the right to an external review by someone who does not work for the plan: a written request within 4 months of the final denial, decided within 45 days, or within 72 hours when expedited. Depending on your state and plan, the review is run by the state, by the federal Department of Health and Human Services, or by an independent review organisation the plan must contract with. Your denial notice and Explanation of Benefits must tell you how to reach it.
The template's closing paragraph puts the plan on notice that you know the second right exists. That sentence changes how carefully the first review is done.
How to fill it
Copy the denial reason word for word into the first paragraph. Do not paraphrase it; the reviewer will check your quotation against the file, and a paraphrase invites a reply about what the plan "actually" said.
The clinical paragraph is facts, not feelings: diagnosis, current BMI with the date it was measured, the weight-related conditions and how long they have been treated, what was tried before and what happened. Take every number from the chart or from your weight and waist tracker; estimates are how appeals lose.
The answering paragraph is the letter. If the denial says documentation was missing, name the enclosure that supplies it. If it says a criterion was not met, cite the criterion from the plan's own policy and the record that meets it. If it cites a formulary exclusion, say so plainly and ask for the exception process; arguing medical necessity against an exclusion wastes the appeal.
The enclosure list should match the order the letter mentions things: denial, prescriber's letter of medical necessity, chart notes, prior-attempt records, labs, and the plan's own criteria with the relevant lines marked. The prior authorization checklist is the inventory for that pile.
What this template is not
It is not legal advice and it does not know your plan. Deadlines printed on the sheet are the federal ones HealthCare.gov describes; the notice from your plan states the ones that bind it, and if they are shorter, the notice wins. Keep copies of everything and note every call by date, as HealthCare.gov also advises. The FormBlends cost report is worth reading in parallel, because the outcome of an appeal is one input to a decision about what you will actually pay.
Questions people ask
Is this the letter of medical necessity?
No. The letter of medical necessity is written and signed by your prescriber and speaks to the clinical facts in their words. This template is your letter as the member: it files the appeal, quotes the denial, points at the evidence and encloses the prescriber's letter. The two travel together.
What if my plan is through my employer and self-funded?
Self-funded employer plans follow federal rules rather than state insurance law, and the external review route may be the HHS-administered federal process or an independent review organisation the plan contracts with. Your denial letter must tell you which. The structure of this template still applies; the addresses and deadlines come from the notice.
Sources
- HealthCare.gov: Internal appeals Accessed September 4, 2026.
- HealthCare.gov: External review Accessed September 4, 2026.
Canonical URL: https://formblendstools.com/templates/insurance-appeal-letter. Written by the FormBlends editorial team. This page is educational and is not medical advice; see the medical disclaimer.