Sample appeal letter for medical claim denial for no authorization

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This appeal letter can be adapted for use when your health insurance company has denied a test, medication, or service before you’ve had it.

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Letter Template: Prior Authorization Denial Appeal

Dear [insert contact name],

We have received a claims denial notification from [insert payer name] for the following service(s):

• Patient Name: [insert patient name]
• Policy ID or #: [insert policy ID or #]
• Authorization #: [insert claim #]
• Date of Service: [insert date of service]
• Services Denied: [insert CPT code]
• Rationale for Denial: [insert denial rationale, if available]

We at [insert practice name] are requesting that [insert payer name] reconsider this claim as medically necessary and deserving of payment. The clinical facts surrounding the services provided support medical necessity and clinical appropriateness of the use of non-invasive prenatal testing (NIPT) for this patient. 

Although chromosomal abnormalities occur in approximately 1 in 150 live births,  the prevalence of chromosomal abnormalities is greater earlier in gestation because aneuploidy accounts for a large proportion of early pregnancy loss. The incidence of fetal chromosomal abnormalities increases as a woman ages but can affect pregnancies of patients at any age and is not related to race or ethnicity. Although the risk of aneuploidy increases with advancing maternal age, most children with trisomy 21 are born to younger patients because a larger proportion of all children are born to younger patients. The American College of Obstetricians and Gynecologists (ACOG) recommends offering prenatal genetic screening and diagnostic testing to all pregnant women regardless of maternal age or risk of chromosomal abnormality.  Improved access to comprehensive perinatal services, including NIPT, empowers all pregnant individuals to engage in their care decisions and prepare for various outcomes identified by NIPT.

In this specific circumstance, [include details surrounding medical necessity and why the test was ordered]. As such, we are requesting these services be covered as medically necessary and clinically appropriate.

Best, [insert sender’s name and signature]

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