Customer Service Department:
writing to appeal [name of medical group OR health plan]'s decision to deny authorization
for [name of service, procedure/ treatment sought] for me. The [medical group OR health
plan] has denied coverage for [name of service, procedure/ treatment], as not medically
necessary. I believe [name of service, procedure/ treatment sought] is medically necessary
to [treat or diagnose/ address] my medical condition and is covered by my health plan.
[Name of medical group/health plan] should approve [name of service, procedure/treatment]
in my case.
would like to inform you that failure to provide immediate treatment for my condition
involves an imminent and serious threat to my health. I am, therfore, requesting an
expedited review of my appeal. Kindly notify me of your decision at the soonest possible.
enclosing documentation of my medical condition, and information supporting the medical
necessity of [name of service/procedure], with this letter. Please let me know if any
additional information will be helpful to my request. I can be reached at [telephone
shall appreciate your immediate attention to this matter.