Your Insurance Denial Is Not Final

LETTER OF MEDICAL NECESSITY

Date: [DATE]
Patient: [PATIENT NAME]
DOB: [DATE OF BIRTH]
Insurance: [CARRIER NAME]
Member ID: [MEMBER ID]
Claim/Auth #: [REFERENCE NUMBER]

Dear Medical Director,

I am writing to establish the medical necessity of [PROCEDURE/SERVICE] for my patient, [PATIENT NAME].

CLINICAL HISTORY:
[Patient has been under my care since DATE for DIAGNOSIS (ICD-10: CODE). Previous treatments have included TREATMENT 1, TREATMENT 2, and TREATMENT 3, which have been insufficient/unsuccessful as evidenced by CLINICAL FINDINGS.]

MEDICAL NECESSITY JUSTIFICATION:
The requested [SERVICE] is medically necessary because:
1. [CLINICAL REASON 1 - cite specific clinical guidelines]
2. [CLINICAL REASON 2 - reference peer-reviewed evidence]
3. [CLINICAL REASON 3 - note functional limitations]

Without this service, the patient faces [SPECIFIC RISK/CONSEQUENCE].

SUPPORTING EVIDENCE:
- [GUIDELINE 1: e.g., AMA CPT guidelines, specialty society recommendations]
- [GUIDELINE 2: e.g., peer-reviewed study citation]
- [GUIDELINE 3: e.g., FDA approval, CMS NCD/LCD reference]

This service meets the plan's definition of medical necessity as it is:
□ Required to diagnose or treat a medical condition
□ The most appropriate level of care
□ Not primarily for convenience
□ Consistent with accepted standards of medical practice

I am available for a peer-to-peer review at your earliest convenience.

Sincerely,
[PHYSICIAN NAME], [CREDENTIALS]
NPI: [NPI NUMBER]
Practice: [PRACTICE NAME]
Phone: [PHONE] | Fax: [FAX]