APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED 
ON GROUNDS THAT IT IS NOT A “COVERED MEDICAL SERVICE”

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 a covered medical service. I request that you reconsider your determination for the following reasons:

(List Reasons That Demonstrate Why the Test/Procedure is a Covered Service)

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). In addition to being a covered benefit, 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)