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Letter of Medical Necessity: What Your Doctor Should Include
The elements that make a letter of medical necessity useful in an insurance appeal, with a sample paragraph.
A letter of medical necessity is often the most important document in an appeal. It should come from your treating clinician and respond directly to the plan's stated denial reason.
Free sample appeal paragraph
I am the treating [specialty] for [patient], whom I have seen since [date] for [diagnosis, ICD-10]. [Patient] has tried [treatments, dates, outcomes]. [Requested service] is medically necessary because [clinical rationale], consistent with [guideline or published evidence]. Without it, [patient] is at risk of [consequence].
Replace the [brackets] with your details. This is a starting point, not legal advice.
What to do
- Diagnosis codes and history
- Treatments tried and why they failed
- Why this specific service is needed now
- Guideline or evidence references
- Risks of not treating
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Start the free checkFrequently asked questions
Can I write my own letter of medical necessity?
Your appeal letter can be written by you, but the medical necessity letter carries more weight coming from your clinician. You can make it easier by giving them a draft or a list of points.
How long should it be?
Usually one to two pages. Specific is better than long.
How do I appeal a letter of medical necessity denial?
Start with the instructions and deadline on your denial letter. Gather your medical records and a letter of medical necessity, respond directly to the stated denial reason, and file an internal appeal. Keep proof of submission.
Is external review available?
For many non-grandfathered plans, independent external review may be available for denials involving medical judgment after a final internal denial, generally within 4 months. Confirm on your denial notice.
Related guides
- ACA Internal Appeal Deadlines Explained
- ACA External Review: How It Works
- Medicare Advantage Organization Determination Appeals
- How to Appeal a Medicaid Denial (Plan Appeal and State Fair Hearing)
- How to Appeal a Medicare Part D Drug Denial
- How to Appeal an Employer Health Plan Denial (ERISA Plans)
- All appeal guides
Document preparation / educational use only. This site is not a law firm, regulator, airline, insurer, or parking operator. Nothing here is legal advice. Outcomes are never guaranteed. Review every letter carefully before sending and consult a licensed professional if you need advice about your situation.