Medical Necessity Appeal Letter
Conflict between providers and insurance companies goes on constantly in regards to procedures and medications for patients. Sometimes a physician will use his or her expertise to determine that a particular procedure or medication is the right approach for restoring the patient to health, but insurance company officials may refuse to pay stating that the procedure or medication was too expensive, not medically necessary and that a less expensive procedure or medication would have helped the patient just as well. These types of conflicts typically result in the filing of a medical necessity appeal letter.
Content and Format
A medical necessity appeal letter format can be tricky. First check the patient’s policy to make sure the procedure is not specifically excluded. In the letter, state the provider’s name, patient’s name, date of service and procedure in question. Also list the patient’s identification, group, policy and claim numbers. Describe treatment that has already been done on the patient, the results of the treatment and the reason the newer, more expensive treatment, was administered. Close the letter by noting how the treatment in question has helped the patient.
New medications are being developed every day for specific ailments and the newest medications are usually the most expensive. This medical necessity appeal letter sample deals with a patient who received the newest type of injection for arthritis in her knee. The injection was expensive and the insurance company declined to pay for it stating that one of the less expensive injections would have sufficed. A representative from the physician’s office is appealing the insurance company’s decision based on the fact that other injections have been given to the patient in the past with no success; therefore the physician elected to try the new medicine which is not an exclusion in the patient’s insurance contract.
I am writing to address the denial issued on September 10, 2013 for our patient Katherine Byrd (information listed above). XYZ insurance company denied the injections of hyalyronan into Ms. Byrd’s knees stating that the use of the new arthritis medication was not medically necessary. XYZ contends that this newer, more expensive arthritis medication did not need to be used for Ms. Byrd and that one of the older, less expensive arthritis injections available today would have sufficed. ABC Arthritis Specialists respectfully appeals this decision.
I have enclosed a detailed history of Ms. Byrd’s battle with arthritis and the treatments, both in pill form and injections, which have been given to Ms. Byrd over the course of the last 3 years she has been seeking treatment from our physicians.As you can clearly see upon inspecting the records, other medications have either never worked for her or worked for a whilebut became ineffective over time. It was the best professional opinion of our physician, Dr. Gregory Pile, that the new hyalyronan injections should be tried on Ms. Byrd. For the record, she has already experienced a decrease in swelling and an increase in mobility in her knees.
We request that XYZ Insurance Company pay for these injections, which are not excluded in Ms. Byrd’s insurance contract. Please contact me at the number or email listed above if you require more information.