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Watch a one-minute video about how our insurance experts can help you with insurance questions and problems.
Treatment that's not medically necessary
Insurance companies deny claims as “medically necessary” when the claim does not meet the insurance company’s internal medical policies. These policies outline requirements that need to be met to cover certain treatments.
You'll need to show the insurance company how you meet the medical criteria they outline in the policy, ask your doctor for written documents explaining why you meet the criteria. You might also want to get proof from other medical experts.
Example of not medically necessary appeal letter (DOC 31.00KB)
Example of not medically necessary appeal letter (PDF 97.50KB)
Mental health and substance abuse
Your health insurer must cover mental health and substance abuse disorders the same way they cover medical and surgical services. Ask your doctor for written documents explaining why it should be covered.
Example letter for a mental health/substance abuse disorder denial (DOCX 19.42KB)
Example letter for a mental health/substance abuse disorder denial (PDF 216.67KB)
Gender-affirming care
Usually, your health insurer can't deny or limit gender-affirming treatment that's medically necessary. Ask your doctor for documents that show why your treatment is medically necessary.
Example letter to appeal denial of prior authorization request for gender-affirming care (DOC 31.00KB)
Example letter to appeal denial of prior authorization request for gender-affirming care (PDF 105.19KB)
Out-of-network providers
Try showing that your plan’s network did not include the type of provider you needed, that the in-network providers were out of your service area (more than 30 miles from you) or that there was a long wait time for an appointment for providers in your plan's network.
Example letter to request payment to an out-of-network provider (DOC 31.00KB)
Example letter to request payment to an out-of-network provider (PDF 71.43KB)
Where you get health care (in-home care vs. hospitalization)
If you show that in-home care would be cheaper than hospitalization and will meet your medical needs, your insurer may cover it. Ask your provider for a written recommendation, including a treatment plan.
Depending on your type of health plan, it may help to tell them about state rules for in-home care.
Example letter to appeal denial based on health care setting (DOC 32.00KB)
Example letter to appeal denial based on health care setting (PDF 102.63KB)
Policy canceled because you didn't pay
Explain why you couldn't pay. For example:
- You had an issue with getting paid for work
- You switched bank accounts and forgot to tell your insurer
- You had trouble signing up for or accessing your online account
Explain that you have been a customer for a long time and have always paid on time. Ask your insurer for a one-time exception to reinstate your policy.
Example letter to appeal cancellation of a policy for lack of payment (DOC 30.00KB)
Example letter to appeal cancellation of a policy for lack of payment (PDF 69.04KB)
When your appeal is denied by your insurer
A review by an independent review organization (IRO) can be requested if your insurer doesn’t change their decision after you appeal it. The IRO will review the appeal and decide whether or not your insurer should cover your claim. To find past IRO decisions about health insurance appeals, search our database.
Example letter to request a second-level (external) review (DOC 26.50KB)
Example letter to request a second-level (external) review (PDF 69.35KB)