Sample Letter 1 regarding medically necessary treatment: Download this letter as Word Document
Sarah Smith is being by Dr. Tom Jones treated for anorexia nervosa. Her physician has prescribed inpatient hospitalization and the insurer has denied coverage on the grounds that the requested care is not medically necessary. The insurance company maintains that it is allowed to rely on it own criteria in making coverage determinations. Sarah has received a written denial of the requested coverage.
June 5, 2007
ABC Insurance Company
1234 Main Street
Jackson, ST 98765
Re: Sarah Smith
To Whom It May Concern:
I am writing you in response to your written denial of June 2, 2007 regarding my daughter, Sarah Smith.
Sarah is a seventeen-year-old who is being treated for an eating disorder, specifically anorexia nervosa. Her condition is characterized by significant food restriction, excessive exercise, with resultant bradycardia, poor perfusion, and cold intolerance. She has lost more than twenty pounds and is now significantly underweight with a body mass index of 15.5 (12th percentile).
Sarah is currently treated by Dr. Tom Jones who can be reached at (444) 555-1234. Dr. Jones has prescribed inpatient hospitalization for Sarah because Sarah is continuing to lose weight despite aggressive multimodal outpatient treatment by Dr. Jones, a licensed psychotherapist, and a registered dietician.
Please consider this letter and written appeal and request for reconsideration on behalf of Sarah Smith.
Consistent guidelines for hospitalization have been defined in published practice guidelines
Section 3 of the Contract allows ABC Insurance Company to adopt "reasonable policies, procedures, rules and interpretations to promote administration of this Contract," however, the contract also requires that you provide coverage for services which are "reasonably necessary and in the exercise of good medical practice in accordance with professional standards accepted and commonly available in the United States for treatment of Sickness and Injuries". The services requested by Dr. Jones satisfy the evidence-based clinical guidelines for hospitalization.
The ABC Insurance Company may not substitute its own treatment criteria for published evidence-based practice guidelines. Therefore, ABC Insurance Company’s decision to deny medically necessary care to Sarah is in violation of the Contract and the requested treatment should be covered by the terms of the Contract without further delay.
If Sarah is not treated according to the doctor's prescription the following medical complications are likely to ensue: EXAMPLE. In the event that these complications arise, ABC Insurance Company would obviously be liable for coverage of treatment, but the cost to ABC Insurance would likely be greater than if ABC Insurance Company would acknowledge the validity of the doctor's current plan. So, covering this requested hospitalization is not only potentially life-saving, it is also cost-effective.
I look forward to your response as soon as possible, and I further request any admission/treatment/or medical criteria you relied on in reaching your current decision to deny care. Any additional delay in the coverage of Sarah’s medical treatment may have devastating consequences, since Sarah’s symptoms, if untreated, could be life-threatening. Sarah’s physician, Dr. Smith, is willing to discuss Sarah’s condition further with you and you may reach him at (444) 555-1234.
Thank you in advance for your prompt attention to this urgent matter.
Sincerely,
Sally Smith
Mother of Sarah Smith