Risk Management

Appeal Letter to MCO When Treatment is Denied (Not Medically Necessary)

APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED ON GROUNDS THAT IT IS NOT “MEDICALLY NECESSARY”

Chairperson

Utilization Review Committee

RE:     (Patient Name)

Patient ID Number

Dear:

On (Date), I prescribed (Test/Procedure) for (Patient’s Name). On (Date), you denied authorization of payment for that (Test/Procedure) on the grounds that it was not medically necessary. I request that you reconsider your determination for the following reasons:

(List reasons that demonstrate why the test is medically necessary)

In my medical judgment, a (Test/Procedure) is a very important part of my overall care of   (Patient’s Name). (Patient’s Name) suffers from (Describe Condition). The (Test/Procedure) is necessary to (Describe Why Necessary). Failure to perform the (Test/Procedure) could result in the following problems:

(Describe problem)

For these reasons, I urge you to reconsider your denial of payment authorization for the procedure I have prescribed. Enclosed are pertinent medical records supporting my recommendation.

By copy of this letter to (Patient’s Name), in my best medical judgment I suggest that he/she obtain the (Test/Procedure), despite your denying payment authorization.

Yours truly,

(Your Name)

cc: (Patient’s Name)