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Insurance denial / prior auth appeal letter

Denied as not medically necessary? Draft a member internal appeal with claim numbers, facts, and a packet checklist plans actually review.

This is for anyone whose health plan denied coverage — a prior authorization, a prescription, an MRI, a procedure — and who now has to write the appeal letter themselves. You enter the facts straight from your denial notice; the AI drafts a formal member appeal structured the way plans expect to see it. It drafts the letter, not the medical argument: pair it with a letter of medical necessity from your clinician for the strongest packet.

Research-informed structure Draft autosaved on this device Copy · print · download Not legal advice
1Mode + IDsPrior auth, medical necessity, OON, or quantity limit.
2Paste denial factsAuth #, reason phrase, clinician, deadline.
3Send packetLetter + denial + clinician note before the deadline.
1 · Mode 2 · Facts 3 · Letter

Build your letter

Draft saved
Prior auth denialOpen with member ID + auth number + service. Ask for reconsideration and a peer-to-peer between the plan medical director and your clinician. Attach the denial letter and clinic medical-necessity note.
Brief strength0%

Add a few key facts to unlock a strong draft.

0 characters · Use real dates and amounts only — leave blanks if you do not know.

Shortcut Ctrl+Enter · Autosaves as you type

Not legal, medical, or financial advice. Review, personalize, and verify deadlines for your state and institution before sending. The AI will not invent account numbers, diagnoses, or statutes.

Your letter

Drafting with care…

Using structured facts — not generic filler
Your letter will appear here.

1. Pick a mode
2. Fill facts (or load an example)
3. Hit Generate

Appeal packet checklist

The letter is half the job. Tap items as you finish them — progress saves on this device.

  • Denial letter / EOB — all pages (deadline is usually on it)
  • Prescription, order, or pre-auth request copy
  • Clinician letter of medical necessity (strongest piece)
  • Chart notes showing failed alternatives / step therapy
  • Relevant imaging, labs, or specialist notes
  • Request peer-to-peer if the plan allows it
  • Calendar the internal appeal deadline; ask about external review rights if denied again

What actually works

Internal then external

Most plans require an internal appeal first. If that fails, many commercial plans allow independent external review under state or federal rules. Deadlines are short — put them on a calendar the day the denial arrives.

Clinician letter wins

Member letters set the frame; a medical-necessity letter from the treating clinician citing failed alternatives and clinical criteria is what medical directors weigh most heavily.

Quote the denial

Copy the plan’s exact denial reason. Then answer that reason point-by-point. Invented policy language hurts credibility.

Peer-to-peer

Ask for a peer-to-peer between the plan’s medical director and your specialist. Put the clinic phone number in the letter so scheduling is easy.

How it works

  1. Pick your denial type. Choose prior authorization, not medically necessary, out of network, or quantity / refill limit. The letter structure adjusts to the denial reason.
  2. Enter the facts from your denial letter. Plan name, member ID, claim or auth number, denial date, the drug or procedure, and the plan’s reason exactly as written. Real details only — leave blanks if you do not know.
  3. Generate, then personalize. The AI drafts the letter in your words. Read it, fix anything it got wrong, and add anything only you know before it goes out.
  4. Assemble the packet and beat the deadline. Send the letter with the denial notice, your clinician’s medical-necessity note, and supporting records — before the appeal deadline printed on the notice.

Common situations

Drug denied after step therapy Your plan refused a prescribed medication because cheaper alternatives were not tried first — or were tried and failed. The letter cites the failed alternatives and asks for a peer-to-peer with your specialist.
Imaging or procedure refused An MRI, surgery, or procedure was denied as not meeting clinical criteria. The draft quotes the plan’s stated reason and answers it point by point with your clinician’s findings.
Out-of-network referral You were sent to a specialist outside the plan’s network — often because no in-network option was available. The letter asks for in-network level coverage and explains why.
Quantity or refill limits A maintenance medication is capped below the dose your clinician prescribed. The appeal requests an exception to the quantity limit with the prescribing details attached.

FAQ

Is what I type private?

Your input is sent to our AI service to generate your result. No account, no signup, and nothing is linked to your identity. We count anonymous usage per tool for analytics. Your text is never sold.

What is the difference between an internal appeal and an external review?

An internal appeal asks your own plan to re-review and reverse its denial. If the plan upholds the denial, many plans offer external review by an independent third party. Most plans require the internal appeal first. Your denial notice should explain both rights and the deadlines for each.

What should I send with the appeal letter?

The letter is only part of the packet. Include the full denial letter or EOB, a letter of medical necessity from your treating clinician, chart notes showing failed alternatives or step therapy, and any relevant imaging, labs, or specialist notes. Request a peer-to-peer between the plan’s medical director and your clinician if the plan allows it.

How long do I have to file the appeal?

Often 180 days for internal appeals on commercial plans — but always use the deadline printed on your notice. Some plans are shorter, and external review has its own separate deadline. Put both on a calendar the day the denial arrives.

Should my doctor write the appeal instead of me?

Strongest packets include a clinician letter of medical necessity — medical directors weigh the treating clinician’s clinical reasoning most heavily. This tool drafts your member appeal letter, which frames the case and attaches everything together. Ask the clinic for the medical-necessity letter and reference it in yours.

The plan said “not medically necessary.” What changes their mind?

A clinical argument that answers their exact stated reason: the diagnosis, the clinical criteria your case meets, what alternatives were tried and why they failed, and records to back it up. Copy the plan’s denial reason word for word and address it point by point. Vague letters lose; specific, documented ones get re-reviewed.

Is this medical or legal advice?

No. It is an educational draft. Follow your plan documents, your clinician’s recommendations, and your state’s appeal rules before sending anything.

Related tools

General Appeal LetterOther appeal types Hardship LetterBilling hardship requests Complaint LetterFormal complaints to plans or regulators Plan ExplainerUnderstand your coverage terms

Want the full process? Read the insurance claim denial appeal guide.