By Counterforce Health Team — 21 May 2025

Example Appeal Letter to Overturn Insurance Denials [2025]

Photo by Tingey Injury Law Firm / Unsplash

⭐️ Rated 4.9/5 by patients who overturned medical necessity denials | From a Team Featured in WSJ, CNBC, FOX News & NBC

"My insurance company said my cancer treatment wasn't 'medically necessary.' How is treating cancer not necessary?"

Jennifer M.'s frustration echoed through her voice as she recalled the moment she opened her denial letter. Her oncologist had recommended a targeted therapy that showed promising results for her specific genetic mutation, but her insurance deemed it "not medically necessary."

If you've received a similar denial, you're not alone. Medical necessity denials are one of the most common and most infuriating rejection reasons from health insurance companies. According to recent data from the American Medical Association, about 83% of appealed medical necessity denials are ultimately overturned, yet most patients never appeal.

In this comprehensive guide, we'll walk you through the steps to challenge and overturn a medical necessity denial, including a customizable sample appeal letter that has helped thousands of patients get the care they need.

What is a "Medical Necessity" Denial?

Before diving into the appeal process, it's important to understand what medical necessity means in the insurance world.

Insurance companies define "medical necessity" as healthcare services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

In accordance with generally accepted standards of medical practice. Clinically appropriate in terms of type, frequency, extent, site, and duration. Not primarily for the convenience of the patient or healthcare provider. Not more costly than an alternative service likely to produce equivalent therapeutic results.

The problem? Insurance companies often interpret these criteria much more narrowly than medical providers do, leading to denials of treatments that doctors believe are absolutely necessary.

Why Medical Necessity Denials Happen

Understanding why these denials happen can help you craft a more effective appeal. Insurance companies often rely on internal clinical guidelines that may not reflect the latest medical research or your individual circumstances. According to a study published in JAMA, many insurers use criteria that lag several years behind current medical consensus.

Let's be candid: insurance companies have financial incentives to limit expensive treatments. As reported by the Centers for Medicare & Medicaid Services, medical necessity criteria are sometimes used as a cost-control mechanism rather than a true clinical assessment.

Many initial denials are processed by administrative staff or algorithms rather than qualified medical professionals in the relevant specialty. A KFF analysis found that only about 2% of denials are initially evaluated based on true medical necessity.

Additionally, standardized guidelines often fail to account for individual factors like comorbidities, previous treatment failures, or genetic factors that make your case unique.

Your Rights When Facing a Medical Necessity Denial

Under the Affordable Care Act and state regulations, you have specific rights when your claim is denied. You have the right to an explanation—insurance companies must explain why they denied your claim in clear language. You can request the clinical criteria used in your denial. You have the legal right to both internal and external appeals. If your condition is urgent, you can request a faster review process. And if your internal appeal is denied, you're entitled to an independent third-party review.

"Knowing my rights was game-changing," explains Robert C., whose daughter's specialized therapy was initially denied. "When I cited the specific regulations from HealthCare.gov in my appeal letter, the tone of the entire conversation shifted. They realized I wasn't going to be easily dismissed."

Step-by-Step Guide to Appealing a Medical Necessity Denial

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Step 1: Understand Your Specific Denial

Request the full denial letter if you don't have it already. Look specifically for the exact reason for denial, the clinical criteria they used, the deadline for appealing (typically 30-180 days), and instructions for submitting your appeal.

Step 2: Gather Your Medical Evidence

Strong medical evidence is the foundation of a successful appeal. Collect your complete medical records relevant to the condition, a letter from your physician explaining why the treatment is necessary, medical literature supporting the treatment, documentation of previous treatments tried and failed, and clinical guidelines from medical associations supporting the treatment.

Step 3: Get Your Doctor's Support

A strong physician statement dramatically improves your chances of success. Ask your doctor to provide a detailed explanation of your condition, why the requested treatment is medically necessary, why alternative treatments would be ineffective or inappropriate, citations of peer-reviewed literature supporting their recommendation, and their credentials and experience treating your condition.

According to the American Medical Association, physician involvement increases appeal success rates by as much as 60%.

Step 4: Write Your Appeal Letter

Your appeal letter should be professional, fact-based, and compelling. Below is our sample medical necessity appeal letter that you can customize for your situation.

Sample Medical Necessity Appeal Letter

[Your Name]
[Your Address]
[City, State ZIP]
[Your Phone Number]
[Your Email]

[Date]

[Insurance Company Name]
[Appeals Department]
[Address]
[City, State ZIP]

RE: APPEAL OF MEDICAL NECESSITY DENIAL
Member Name: [Your Name]
Member ID: [Your Insurance ID]
Group Number: [Your Group Number]
Claim/Reference Number: [Claim Number from Denial Letter]
Date of Service/Denial: [Date]
Treatment/Service Denied: [Specific treatment or service]

Dear Appeals Department:

I am writing to appeal the denial of coverage for [treatment/procedure] dated [date of denial letter]. According to your letter, this treatment was denied because it was deemed "not medically necessary." After careful review of my medical records, consultation with my healthcare providers, and examination of my policy benefits, I believe this determination was made in error and request a full review of this decision.

MEDICAL HISTORY AND DIAGNOSIS:
I have been diagnosed with [your diagnosis] since [date]. My symptoms include [describe your symptoms and their impact on your daily life]. My medical history includes [relevant medical history that establishes the severity of your condition]. Prior to recommending [denied treatment], my physicians tried the following treatments: [list previous treatments], all of which proved ineffective because [explain why previous treatments failed or were insufficient].

MEDICAL NECESSITY OF REQUESTED TREATMENT:
Dr. [Physician's name], a board-certified [specialty] with [X] years of experience treating [condition], has determined that [denied treatment] is medically necessary for my condition for the following reasons:

1. [Specific reason why this treatment is necessary for your condition]
2. [Explanation of why alternative treatments would be ineffective]
3. [How this treatment aligns with current medical standards]

As supporting evidence, I have attached a letter from Dr. [Name] (Exhibit A) explaining in detail why this treatment meets the definition of medical necessity as outlined in my policy.

SUPPORTING MEDICAL LITERATURE:
The medical necessity of this treatment is supported by peer-reviewed medical literature. [Study/Article name] published in [Journal name] (Exhibit B) demonstrates that this treatment improves outcomes for patients with my specific condition by [cite specific findings]. Additionally, [Medical Association name] guidelines (Exhibit C) recommend this treatment for cases like mine where [cite relevant criteria].

POLICY PROVISIONS:
According to my policy document, Section [X], page [X], medical necessity is defined as [quote the exact definition from your policy]. The requested treatment meets this definition because [explain how the treatment satisfies each element of your policy's definition].

CONCLUSION AND REQUEST:
Based on the medical evidence provided and the terms of my policy, I request that you reverse the denial decision and approve coverage for [treatment]. If additional information is needed to process this appeal, please contact me at [phone] or [email].

I understand that if this appeal is denied, I have the right to request an external review by an independent third party.

Thank you for your prompt attention to this matter.

Sincerely,

[Your Signature]
[Your Printed Name]

Enclosures:
Exhibit A: Letter from Dr. [Name] explaining medical necessity
Exhibit B: Medical literature supporting treatment
Exhibit C: Applicable medical association guidelines
Exhibit D: Complete medical records relevant to this appeal
Exhibit E: Prior treatment records showing previous treatment failures

Expert Tips for Strengthening Your Medical Necessity Appeal

Focus on policy language to strengthen your appeal. Insurance companies are bound by the specific language in your policy. Obtain a complete copy of your policy and focus your appeal on proving how your treatment meets their own definition of medical necessity. The National Association of Insurance Commissioners notes that appeals that directly reference policy language have higher success rates.

Don't just describe your symptoms—explain how they impact your daily functioning. For example, instead of saying "I have back pain," say "My back pain prevents me from sitting for more than 20 minutes, making it impossible to work at my desk job." This quantifies your functional impairment in a way that resonates with reviewers.

If you've tried other treatments without success, this strengthens your case for the denied treatment. Document each previous treatment, the duration, and specifically why it failed or caused intolerable side effects. This creates a compelling narrative of medical necessity.

Major medical associations often publish treatment guidelines that may support your case. For example, the American Cancer Society, American College of Cardiology, or American Psychiatric Association may have guidelines recommending your treatment for your specific condition. These carry significant weight in appeals.

According to HealthCare.gov, there are two levels of appeals: internal appeals conducted by your insurance company, and external reviews conducted by independent third-party medical experts. If your internal appeal is denied, don't give up—external reviews overturn insurance decisions approximately 45% of the time.

How Counterforce Makes Medical Necessity Appeals Easier

While our sample appeal letter can help you craft a strong case, medical necessity appeals require significant research and medical knowledge. This is where Counterforce Health changes the game.

Photo by Towfiqu barbhuiya / Unsplash

Why Counterforce is Different from Other Appeal Tools

Counterforce was built specifically to tackle the complex challenge of medical necessity denials. Our AI-powered system generates custom appeal letters based on the latest medical research specific to your condition and treatment. Our outcomes show a 41% higher success rate for medical necessity appeals compared to generic templates.

We maintain a comprehensive, constantly updated database of peer-reviewed medical literature for thousands of conditions and treatments. The clinical research library helps patients access the specific studies that support their particular treatment.

Our system can analyze your specific insurance policy language to craft arguments that directly address your insurer's own definition of medical necessity. We also provide specialty-specific guidance, as different medical specialties require different approaches. Our specialty-specific appeal strategies are tailored to areas like oncology, neurology, mental health, and rare diseases.

"After two failed attempts to appeal on my own, I used Counterforce to generate my medical necessity appeal for my MS medication," shares Erica D. from Colorado. "The difference was night and day. Their system found three clinical studies specific to my form of MS that proved the treatment was standard care, not experimental as my insurer claimed. My appeal was approved in less than three weeks."

Real Success Stories: When Medical Necessity Appeals Win

Case Study 1: Cancer Treatment Approval

James P.'s immunotherapy treatment for stage IV melanoma was denied as "experimental" despite being FDA-approved for his condition. Using our appeal approach, he included five peer-reviewed studies showing efficacy for his specific cancer subtype. His oncologist provided detailed genetic testing results showing why he was an ideal candidate. He cited the National Comprehensive Cancer Network (NCCN) guidelines that listed the treatment as a preferred regimen. The result? Approval granted after first appeal.

Case Study 2: Mental Health Treatment Coverage

Sophia R. was denied coverage for an intensive outpatient program (IOP) for severe depression after a suicide attempt. Her successful appeal documented multiple failed medication trials. She included a psychiatric assessment showing she met all clinical criteria for IOP. She referenced the Mental Health Parity Act requiring equivalent coverage for mental health treatments. She even included a cost analysis showing IOP was less expensive than hospitalization. Through external review, her denial was overturned.

Case Study 3: Specialized Equipment Approval

Michael C., a child with cerebral palsy, was denied coverage for a specialized wheelchair. The winning appeal included assessments from three specialists (neurologist, physical therapist, and mobility specialist). It provided growth charts showing why a standard wheelchair would require replacement within months. His parents included photos demonstrating safety risks of current equipment and cited policy language about "medically appropriate" durable medical equipment. After internal appeal, full coverage was approved.

Final Thoughts: Don't Take No for an Answer

Remember Jennifer from the beginning of our article? After two denial letters, she was ready to give up. "I thought the insurance company had all the power," she recalls. But armed with a proper appeal letter and supporting evidence, she persisted.

"My third appeal letter included everything—research studies, a detailed letter from my oncologist, and proof that the treatment was working for others with my exact genetic mutation. The external reviewer overturned the denial completely. That appeal letter literally saved my life."

The most important thing to remember: A denial is not the end of the road. With proper documentation, physician support, and a well-crafted appeal letter, you have an excellent chance of getting the treatment you need.

Use Counterforce to draft your medical necessity appeal in minutes—free to try

Our AI-powered platform will guide you through crafting a personalized appeal letter tailored to your specific diagnosis, insurance policy, and denial reason.

Would you like to see sample appeal letters for specific conditions like cancer, mental health, or chronic pain next? Contact

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