Q&A: Appeal letters for medical necessity denials

Q: Our facility does not have a standard appeal letter template to respond to medical necessity denials. Do you have any suggestions for how to respond? 

A: The key to a good appeal letter is to explain and prove the medical necessity of the service. When writing a letter of appeal for medical necessity, use the suggestions in the following list to make your case:

• Avoid criticism of the healthcare plan, preauthorization, or predetermination system
• Be clear and use medical facts
• Be positive and avoid anger and/or snide comments
• Thoroughly explain why you feel that the patient needs what you prescribed

In some cases, both the provider and the patient should file a letter of appeal. The patient may also want to file a grievance and/or request a fair hearing depending on the type of insurance the patient has for coverage.

Editor’s note: This question was adapted from the HCPro book The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC.

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