Free appeal letter 13Free appeal letter 13Free appeal letter 13
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FIRST LEVEL APPEAL
Your Name
Address
City State Zip
Phone numbers
Email address
DATE
HEALTH PLAN NAME
ATTN: GRIEVANCE AND APPEALS DEPARTMENT
ADDRESS
CITY STATE ZIP
RE:

First Level Appeal of Denial of Medically Necessary Treatment
Claim number:
Member/Subscriber Name:
Member/Subscriber No.:
Group no.:

Dear Grievance and Appeals Manager:
I am writing to appeal the health plan’s denial of medically necessary treatment prescribed by my physician,
Dr.
. My physician prescribed (treatment/test/x-ray/drug/durable medical
equipment) in order to treat (condition). This course of treatment is prudent and necessary in order to improve,
and ultimately maintain my health. In the absence of the medically necessary care prescribed by my doctor,
my condition will worsen and irrevocably compromise my health.
Please reconsider your position and allow my doctor to treat me in accordance with my medical needs and not
based on the economics of the health plan. The treatment and/or services prescribed are