Medical-necessity appeal

For a claim denied as not medically necessary (CARC 50). You supply the clinical rationale and documentation; the letter is a frame for your own words.

The letter

[DATE]

[PAYER NAME]
Attn: Appeals Department

Re: Appeal of medical-necessity denial
Patient: [PATIENT NAME]
Date of birth: [PATIENT DATE OF BIRTH]
Member ID: [MEMBER ID]
Claim number: [CLAIM NUMBER]
Date(s) of service: [DATE(S) OF SERVICE]
Procedure code(s): [CPT CODE(S)]

To whom it may concern:

I am appealing the denial of the above claim, which was denied as not medically necessary (reason code [DENIAL CODE FROM THE REMITTANCE]) on the remittance dated [REMITTANCE DATE].

Diagnosis: [DIAGNOSIS AND ICD-10 CODE]

[STATE, IN YOUR OWN CLINICAL WORDS, WHY THE SERVICE WAS MEDICALLY NECESSARY FOR THIS PATIENT — the presenting problem, functional impact, treatment goals, and why this service and frequency were appropriate.]

[IF THE PAYER HAS A PUBLISHED MEDICAL-NECESSITY OR COVERAGE POLICY FOR THIS SERVICE, DESCRIBE HOW THE TREATMENT MEETS IT.]

I have enclosed [LIST YOUR SUPPORTING DOCUMENTATION — e.g. a treatment summary or records you are choosing to release]. Please overturn this denial and process the claim. I can be reached at [PROVIDER PHONE].

Sincerely,

[PROVIDER NAME AND CREDENTIALS]
NPI: [PROVIDER NPI]
[PROVIDER ADDRESS]
[PROVIDER PHONE]