Key points
- A personal statement is your own account of how the condition and the denial affect your life. It adds to your doctor's letter and does not replace it.
- Use dates, examples and numbers you can stand behind. Describe what you can see and do, and leave medical conclusions to your doctor.
- Keep a short log of symptoms and missed activities now, so the statement rests on records and not on memory.
- The plan must consider everything you send, but a statement does not decide the result.
Your doctor’s letter explains the medicine. Your personal statement explains what the condition, and the missing care, have done to your life. It is a short page in your own words, with dates and examples. It helps a reviewer who has only read papers see the person behind them.
What this means
The people who decide appeals read a file. A medical record says what was found and done. It rarely says what you could not do last month, what you gave up, or what happened on the day you went without the treatment. That is what your statement is for.
A statement is evidence of your experience. It is not a medical opinion and it is not a complaint. It works best when it is specific, calm and true. The Arthritis Foundation lists emotional and over-detailed appeals among the reasons appeals fail, and its advice for appeal letters is to stick to facts.
The plan must consider all the written comments, documents and records you send. That includes your statement. It is a supporting page, not a substitute for your doctor’s letter or the records.
What to do
- Start a log today (your step). Each day or week, write the date, your symptoms in your own words, what you could not do, what it cost you in time, pain or worry, and any care you skipped or delayed. A few lines is enough. A log written at the time is easier to trust than a memory.
- Use prompts to get started. Community Health Advocates’ medical necessity packet uses questions such as “How do you feel when you miss treatments?” Ask yourself:
- What is the condition, in a sentence?
- What treatment did the plan refuse, and what happened on it before?
- What has happened since the denial?
- What can you not do now that you could do before?
- What are you asking the plan to do?
- Write it in this order. Who you are, briefly. The condition and the care you were getting. What the denial changed, with dates. What a normal week looks like now. What you are asking for.
- Be specific. “I missed 6 days of work in March” tells the reviewer more than “I am struggling”. Use numbers only if you can back them up from your log or records.
- Say what you know, not what you guess. Write “my doctor told me” for medical statements and name the doctor. Leave out diagnoses and predictions your doctor has not made.
- Keep it short. Cut anger and blame. State the facts and the request.
- Sign and date it. Add your name, member number and claim number at the top so the page stays with your file.
- Check what you are comfortable sharing. Everything you send goes into the file the plan keeps. Leave out anything you do not want in it.
- Send it with your appeal. Put it after your doctor’s letter in the packet. See how to assemble and send an appeal packet.
An example
This example is made up to show the style. Use your own facts.
My name is [name]. I have [condition], and since [date] I have been treated with [treatment]. On [date] the plan denied [service]. Since then I have [specific change, such as missing work, stopping an activity, or going without care]. My doctor, [name], told me that [what the doctor said]. Before the denial I could [example]. Now I [example]. I am asking the plan to approve [service] so that I can [what it would allow].
If you are writing for someone else
If you are a parent, partner or caregiver writing for a patient, say who you are and how you know the person. Describe what you have seen yourself. A plan must let an authorized representative act for a claimant, so ask the patient to name you. Use the authorized representative designation and see how to act for someone else and how to support a patient’s appeal.
What the plan may say, and what to say back
“We cannot consider personal accounts.” The plan must consider all written comments, documents and records you submit. Ask the plan to confirm in writing that it has your statement in the file.
“This is not medical evidence.” Agree, and point to your doctor’s letter and records for the medical case. The statement shows the effect on your life.
The rule
On appeal, a claimant may submit written comments, documents and records, and the plan must consider all of it, including material not submitted or considered in the first decision. See section 2560.503-1(h)(2)(ii) and (iv) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.
Watch for
- Overstating. Do not exaggerate. If a detail is wrong, it can undermine the rest.
- Medical advice. Do not tell the reviewer what treatment is right. Say what you are experiencing, and let your doctor say why the care is needed.
- A one-size letter. A statement copied from a template reads as generic. Use your own words.
- Your health. Do not stop or change treatment or medication because of an appeal. Talk to your doctor.
- Deadlines. The plan must give you at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls. Do not let writing hold up your appeal.
What next
- How to write an appeal letter that works: where the statement fits.
- What a strong letter of medical necessity contains: the medical case that sits beside yours.
- How to keep a call log and paper trail: a record that supports your account.