Start with the denial reason, not your story
The single biggest mistake in appeal letters is leading with a general explanation of medical need rather than directly addressing the specific reason coverage was denied. Find the exact denial code or explanation on your denial letter before writing anything — this is the target your appeal needs to hit. This guide complements our broader overview of what a successful appeal campaign looks like.
A working structure
1. Identify the claim and denial clearly. Include your member ID, the specific medication and date of the denied claim, and the exact denial reason as stated by the insurer, at the top of the letter.
2. Directly rebut the stated reason. If denied for "not medically necessary," include specific clinical documentation: BMI, relevant comorbidities, prior treatment history. If denied for "step therapy not completed," document any prior relevant treatment attempts, or ask your prescriber for a step-therapy exception based on your specific medical history. If denied as an "excluded benefit," you may need a different approach entirely — check whether the exclusion is plan-wide (in which case appeal may not be the right lever — see our guide on employer plan coverage instead).
3. Include supporting clinical documentation. Ask your prescriber's office for a letter of medical necessity, relevant lab values, and treatment history — this is usually more persuasive coming with clinical backing than from the patient alone.
4. State clearly what you're asking for. Be explicit: approval of the specific medication, dose, and duration your prescriber has prescribed.
5. Note any time sensitivity, if applicable — a documented health risk from delay strengthens urgency without needing to be dramatic about it.