Internal appeal after a denial

[DATE]

[INSURER NAME]

Attn: Appeals Department

[INSURER ADDRESS OR FAX]

Re: Internal appeal of denial

Member name: [YOUR NAME]

Member ID: [MEMBER ID]

Claim / reference number: [NUMBER FROM DENIAL LETTER]

Date of denial: [DATE]

Service or drug denied: [ITEM]

To whom it may concern,

I am appealing your denial dated [DATE] for [ITEM]. The stated reason for denial was: "[QUOTE THE EXACT REASON FROM THE LETTER]."

That reason does not hold for the following reasons:

[Use only what applies.]

1. The denial states the item is not medically necessary. My prescriber, [PRESCRIBER NAME], has documented that it is. Their statement is enclosed.

2. The denial states a covered alternative exists. I have already tried [ALTERNATIVE] and the outcome was [SPECIFIC OUTCOME, with dates].

3. The denial states required documentation was missing. The documentation is enclosed and was [originally submitted on DATE / not requested from me before the denial].

4. The denial applies a step therapy requirement. I am requesting an override on the grounds that [I have already failed the required drug / it is contraindicated / I am currently stable on the requested therapy].

I have insulin-dependent diabetes. Interruption of [ITEM] creates a direct risk of severe hypoglycemia and diabetic ketoacidosis, which is a life-threatening emergency that leads to hospitalization.

I am requesting:

- Reversal of the denial and coverage of [ITEM].

- A written decision that states the specific plan provision relied upon.

- [If urgent:] Expedited review. A delay would seriously jeopardize my health and my ability to regain maximum function.

If this appeal is denied, please provide written instructions for the next level of appeal and for independent external review, including the filing deadline.

Sincerely,

[YOUR NAME]

[PHONE]

[EMAIL]

Enclosures: denial letter, prescriber statement, clinical records, prior trial documentation