APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED - DOC

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APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED - DOC Powered By Docstoc
					           APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED
              ON GROUNDS THAT IT IS NOT “MEDICALLY NECESSARY”



Chairperson
Utilization Review Committee


RE:     (Patient Name)
        Patient ID Number


Dear:

On (Date), I prescribed (Test/Procedure) for (Patient’s Name). On (Date), you denied
authorization of payment for that (Test/Procedure) on the grounds that it was not medically
necessary. I request that you reconsider your determination for the following reasons:

(List reasons that demonstrate why the test is medically necessary.)

In my medical judgment, a (Test/Procedure) is a very important part of my overall care of
(Patient’s Name). (Patient’s Name) suffers from (Describe Condition). The (Test/Procedure) is
necessary to (Describe Why Necessary). Failure to perform the (Test/Procedure) could result in
the following problems:

(Describe problem)

For these reasons, I urge you to reconsider your denial of payment authorization for the
procedure I have prescribed. Enclosed are pertinent medical records supporting my
recommendation.

By copy of this letter to (Patient’s Name), in my best medical judgment I suggest that he/she
obtain the (Test/Procedure), despite your denying payment authorization.

Yours truly,

(Your Name)


cc: (Patient’s Name)