Internal appeal letter template for a gender-affirming care denial

[Your name] · [Member ID] · [Claim or reference number] · [Today's date]

To: [Plan or insurer appeals address from your denial letter]

Re: Appeal of adverse benefit determination dated [date of decision], claim [number]

I am appealing the denial of coverage for [procedure or service, with CPT codes if you have them], denied on [date of decision] for the stated reason [quote the reason from the letter, word for word].

[If any part of this was already approved, say so here, before any argument: On [date] you approved [what] as [medically necessary / covered]. That determination is not in dispute. What is in dispute is [the one remaining question]. This narrows the appeal to a single issue and it is their own finding, not your claim.]

I am requesting: (1) that the determination be reversed and the service approved; (2) a copy of all documents, records, internal rules, guidelines, and clinical criteria relied on in making this determination; (3) the credentials and specialty of the reviewer who made it; and (4) if the determination is not reversed, that you identify specific in-network providers within [distance] of my home who can schedule this procedure within [number] business days, giving the provider name, confirmed availability, and a scheduled date rather than a directory listing.

The determination should be reversed because [state your reason: the criteria are met and here is how; or the exclusion does not apply to this plan or this service; or the reviewer lacked relevant expertise].

Enclosed: [letters from clinicians, clinical records, the plan's own criteria, prior authorization correspondence].

If any part of this appeal is denied, please treat this letter as also requesting external review and provide the instructions and deadline for it.

[Signature] · [Phone] · [Address]

Lead with the ground the plan cannot dispose of in one line. Under 29 CFR 2560.503-1(m)(1)(i)(B) a claim is urgent if the delay would subject you to severe pain that cannot be adequately managed without the care you are seeking — and under (m)(1)(iii), where a physician with knowledge of your condition determines the claim is urgent, it SHALL BE TREATED as urgent. That is not the plan’s judgement to substitute.

So the sentence to add near the top is: I am requesting an expedited appeal under 29 CFR 2560.503-1(m)(1)(i)(B) because delay would subject me to severe pain that cannot be adequately managed without the requested care, and my treating physician has so determined — see the enclosed statement. Then enclose two lines from your clinician saying exactly that.

A lost surgical date is worth naming SECOND, not first. It is real, and it is also the ground a reviewer can downgrade in a sentence as an administrative inconvenience rather than a medical one — which costs about thirty days. Scheduling harm supports the argument; severe pain and the physician determination are the argument.

Plan-type note: the provision above is the ERISA claims regulation, so it governs employer, marketplace and individual plans. Medicaid and Medicare both have expedited routes of their own, on their own clocks — ask for expedited handling by the name your programme uses.