How to File a Medical Appeal: A Case Study

In this episode, we discuss a particular medical appeal process we were involved in for a client. While discussing the particulars of the denial, we go over the dos and don’ts, what information to include in an appeal letter, with whom you can partner in gathering “evidence,” and more.

Episode In Depth

How to File a Medical Appeal: A Case Study

Many of you may have experienced a denial of medical service(s) in the past and know how difficult and frustrating it can be, especially if you were not successful in getting the denial overturned. For others, this may be your first time dealing with what is not only frustrating, but time consuming. While we are not able to guarantee that you will be able to overturn a denial, we can give you the most important steps to take that can result in a more favorable outcome.

There are some definite “do’s and dont’s” that are important to consider. During this podcast, we are providing you with a comprehensive checklist, so you are best prepared. But, before you begin to dive in and write your appeal letter, it’s a good idea to first take a couple of deep breaths, stay calm, and try to maintain a positive state of mind which is important to keep throughout the process – and it is a process. If that doesn’t work, hit your head against the wall a couple of times – not an approach we advocate.

So, here are 6 important “Do’s.”

1. Carefully read all the information on the denial letter to be sure it is accurate. This includes your personal information – who is the policy holder, is all the contact information correct.

2. Read the denial language so you are sure what is denied and the stated reason why it was denied. Compare the service that has been denied to what’s found in your health insurance policy’s coverage guidelines called the “EOC” or “Evidence of Coverage.”

3. At this point, you may not fully understand what’s denied and the reasons for the denial. It’s a good idea to contact your insurance broker if you know them, your company’s HR department, or your treating healthcare professional.

4. Once you fully understand the “what and why” of your denial, it’s time to do a bit of research. You can review published and acceptable treatment guidelines from the medical industry – like the American Medical Association (AMA), the American College of Surgeons, or other professional medical societies, especially when a specialty service was denied. After review of these guidelines, see if they apply to the denied service that was requested by your healthcare professional.

Here are some important and credible resources:

Forget Dr. Google.  It’s always best to find reliable health websites.

Here’s a short list to guide you for gathering credible medical information

Medline Plus
PubMed Central
Center for Disease Control
Mayo Clinic Health Information
CAPHIS: Consumer and Patient Health Information Services
Johns Hopkins Medicine:
Web MD

There are, of course, many other credible health information websites to consider. These are just a few to help you get started.

It’s important to look for any published outcomes in which the proposed treatment, test, or medication resulted in better outcomes and/or was a cost-saving approach. Keep this research available as you’ll need it when writing your appeal letter. Remember, your health plan typically is interested in not only what’s considered to be safe for you as a patient, meets their medical necessity guidelines, but also what can save them money.

5. Now that you are properly armed with what I consider to be most of the important information necessary, you’re ready to start writing the actual letter. Again, recheck that all the information on the denial letter is accurate: name, policy number, policy holder, date of birth, and your contact information for follow up. Next, here’s where attention to detail on your part is crucial: it’s called documentation. A good practice is to keep everything related to your appeal in a separate folder. It will make things easier when writing your letter and any responses afterwards. Include all prior treatments, tests, medications, diagnostic imaging – like X-rays, CT scans, MRI’s, ultrasounds – and procedures. Include the dates and if possible, copies of the results of each. This is particularly important especially when prior authorization was required by your health plan. In other words, sometimes your healthcare professional may not have requested a test, medication, procedure, etc. when the health plan required that they be contacted first – called the prior authorization clause. It’s a pain for the office staff and can easily be overlooked, but a necessary step to have a service covered.

In addition, it’s important to explain why you and/or treating physician believes why that the denied service is necessary. This is moving into an area on which Alan will shed some light discuss during a future podcast called “Medical Necessity – What Is It?” If prior authorization was completed, include a copy. If a surgical procedure was planned and you had a 2nd opinion, include the documentation from this. In all instances, also include all prior correspondence – written letters, emails, and phone calls.

An Important Note:

Whenever you speak with someone at your health plan, it’s very important to keep a record in a folder: take down their name, position/role (they will be a first line customer service rep, typically), telephone number, and extension. You may need this later.

If you have done research, include these materials as well. Make sure they are from credible sources – not a random comment found on the web. Articles that are from peer-reviewed sources are really the “gold standard” here.

6. Now you are ready to send and track your letter. If you mail the letter, it’s best to have it sent as certified mail with a return receipt. If you don’t mind the expense and time is of the essence, you can send it via UPS or FedEx next or 2nd day delivery. If the letter is faxed, keep a copy of not only the fax but have a copy of the transmission report to document that it was successfully transmitted. For an email response, keep a copy of your “sent” file. Most importantly, keep a copy of the letter itself.

When writing your letter, the opening statement is very important. It’s best to be brief, to the point, and clearly state why you are writing the letter. Of course, you should include all your identifying information (name, policy number, claim number, reference to the denial notification). Then state what coverage was specifically denied, your health plan’s reason for the denial, and that you are appealing their decision. Remember that the letter is to orient the reader what you want, why you want it and when you want it – and you are including the information they want.

Here are the 4 important don’ts:

  1. Don’t accept the denial as being final and think you can’t do anything about it
  2. Don’t be so frustrated that you are paralyzed and unable to mount an effective and well-written challenge to the appeal.  You can and you should.
  3. Don’t call your health professional’s office until you have reviewed the denial letter and understand what is being denied, why it was denied, and what your policy coverage is regarding the denied service
  4. And lastly, don’t be afraid to ask for help from your insurance broker, a healthcare professional, and possibly your HR department

In the case where you have already appealed and still been denied through your health plan’s internal review process, specifically for medical necessity, you have the right to an independent medical review called an “External Appeal.” The federal government requires every state to have an external review process that at a minimum meets what’s called “federal consumer protection standards. If your state doesn’t have these standards, the federal government can step in and will oversee your external review process. Sometimes, your health plan may use an independent review organization.  If your coverage is through Medicare, visit for further information.

These appeals are not the standard type which will be referred to in your letter.  The State Department of Insurance or similar entity only reviews to see if the carrier or administrator has made procedural errors.  They do not and cannot comment on the medical legitimacy of your appeal.

Note:  There are requirements to file an external appeal within a certain timeframe, so be sure you are aware of these. Otherwise, your appeal will automatically be denied. 

There is some good news – relatively speaking – is there are other avenues of help that are available to you. Consider using any or all the following organizations: