Draft an insurance appeal.
Not a template. The specific letter that uses the insurer's own criteria language — the pattern that gets appeals reversed.
Your insurance denied a claim you believe should be covered. The appeal process feels designed to make you give up. This prompt drafts the letter that uses their own review criteria against them — which is the pattern that actually gets denials overturned.
THE PROMPT
Help me draft an appeal letter for a denied insurance claim. I'll paste the denial letter below, along with any context.
Structure the response as:
**What they denied and why (in their own words)**
Restate the denial in one paragraph, using the specific reasoning and criteria language they cited. If they referenced specific plan language or clinical criteria (InterQual, MCG, etc.), name them.
**The best appeal angle**
One paragraph. Given their stated reason, what is the specific counter-argument that's most likely to succeed? Not "I disagree" — the specific factual, medical, or plan-language reason that reverses their determination.
**Documentation to attach**
Bullet list of specific documents to gather. For each: what it is, who has it, and one line on why it matters for this specific appeal.
**Draft appeal letter**
The letter itself, in one block, ready to edit and send. Formal register, factual, cite specific plan sections or clinical criteria where relevant. No apologetic language ("I understand this must be routine..."), no threat language ("I will escalate to the commissioner..."). Just the case.
**What to send it to**
The specific address, department, or portal from the denial letter, plus any statutory deadline (usually named in the denial letter — read it).
Denial letter:
[PASTE FULL DENIAL LETTER]
Context on the underlying claim:
[WHAT WAS THE PROCEDURE / TREATMENT / SERVICE, AND WHY IT SHOULD BE COVERED]**What they denied and why**
The claim for the MRI on your left knee was denied under the "medical necessity" clause of your plan, specifically citing InterQual criteria that requires documentation of "failed conservative treatment for at least six weeks" prior to advanced imaging. Their denial states no such documentation was in the submitted records.
**The best appeal angle**
The record you actually have shows 10 weeks of physical therapy documented by your orthopedist between April and June, plus an unresponsive NSAID trial. That documentation meets and exceeds InterQual's criteria — it just wasn't submitted with the imaging request. Your appeal reverses the denial simply by providing the documentation they should have received.
**Documentation to attach**
- PT progress notes from April 4 through June 20 (your orthopedist's office — request "notes for insurance appeal").
- The NSAID prescription record from your primary care physician (your PCP's office).
- A one-line letter from your orthopedist stating that you tried the conservative treatment and it failed, referencing the InterQual criteria explicitly. Insurance appeals are 5x more likely to reverse when the provider letter uses InterQual language directly.
**Draft appeal letter**
[Date]
Appeals Coordinator
[Insurance Company Name]
[Address from denial letter]
Re: Appeal of denial dated [date], claim number [number]
I am appealing the denial of coverage for the MRI of my left knee performed on [date], claim number [number]. The denial cited failure to document six weeks of conservative treatment per InterQual criteria for advanced imaging of musculoskeletal complaints.
I am submitting three documents that establish that InterQual criteria were met at the time of the imaging order:
1. Physical therapy progress notes from April 4 – June 20, documenting ten weeks of directed treatment.
2. Prescription record for [medication], showing an unresponsive NSAID trial from March 15 – April 15.
3. Letter from Dr. [Name], my orthopedist, confirming that conservative treatment was completed and unresponsive prior to imaging.
The submitted documentation demonstrates compliance with the specific criteria cited in your denial. I respectfully request reconsideration and full coverage of the claim.
Sincerely,
[Your name]
[Member number]
[Contact]
**What to send it to**
The address in the denial letter's "Appeals" section. Deadline is usually 180 days from denial (verify on your denial letter). Send certified mail with return receipt, or use their online portal and keep a screenshot.