[Your Full Name]

[Your Address]

[Your Telephone Number]

[Date]

[Address]

Re: [Name of Beneficiary], Member # [Member ID Number] Claim # [Claim Number]

To Whom It May Concern:

I am writing to request a review of your denial of my claim for [service] by [name of provider]. I received your denial letter on [date]. The reason for denial was listed as [reason listed for denial].

I have reviewed my policy and believe that [name of health care plan] is required to cover this service. [Service] is evidence-based and is medically necessary in order to ensure that [Beneficiary] can communicate effectively. 

I am attaching a letter from [Beneficiary]’s [type of treatment provider], [name], explaining that this intervention is evidence-based and medically necessary due to [describe specific needs of the beneficiary that will be addressed by the service]. The intervention will address these needs by [describe what is involved in the intervention].

If applicable, add: [Beneficiary] is not already receiving this service through the IDEA. I am attaching a copy of [his/her] most recent IEP. [Add details, if necessary, explaining why the service is different from those described in the IEP - e.g., the beneficiary is working towards different goals at school than those that the requested service would work towards; the beneficiary is only receiving the service during school hours and needs access to the same service outside school hours, etc.]

[Add more detailed information if possible. If you are including other documents such as prior assessments, journal articles, or other information, include a list of what you are sending here.] 

If you need additional information, I can be reached at [telephone number and/or e-mail address]. 

Sincerely,

[Signature]

[Typed Name]