Appeal: not a covered benefit
Asks your plan to name the exact provision it relied on and to cover care that falls within a benefit your plan document describes.
- Private: nothing leaves this tab
- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan says a service is excluded or not a covered benefit and you think your plan document covers it. The plan document and the denial notice must be in front of you.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: not a covered benefit Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied [The care or drug that was denied] ([Date of the care], [Doctor, hospital or pharmacy]) as not a covered benefit. I ask you to reverse that decision and cover and pay for this care under [Name of the health plan], member ID [Member ID].
The plan gave this reason: [The reason the plan gave] The plan relied on this wording: [The plan wording the denial relies on] I ask the plan to identify the exact provision it relied on and to explain why it applies to this care. If the wording can be read more than one way, I ask the plan to explain why it chose the reading that excludes my care.
My plan documents also say: [Plan wording that covers this kind of care] This care falls within that coverage because: [Why this care fits that coverage] My treating doctor is [Your treating doctor's name and specialty].
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), a denial notice must state the specific plan provisions relied on, and I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Please consider every document and comment I send, including anything that was not before the first reviewer. If the decision depends on a medical judgment, I also ask that you consult a health care professional with training and experience in the relevant field who was not consulted on the first decision.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will pursue every further review available to me, including external review if my case qualifies and a complaint to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. The pages of my plan document I rely on 3. Letter from my treating doctor, if I have one 4. Relevant pages of my medical records
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- The pages of my plan document I rely on
- Letter from my treating doctor, if I have one
- Relevant pages of my medical records
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls.
- Read your plan document again for the benefit your care fits, and for any exception to the exclusion. State law or the plan document can give more rights than the federal minimums, so check your state's page on this site.
- If the plan says no again, ask whether external review is open to you. Federal external review covers denials that involve medical judgment, so a pure exclusion may not qualify, but a denial that turns on medical necessity or on an exception can. Check the date on your notice, which controls.
- You can also complain to the agency that oversees your plan. A complaint does not stop your appeal deadline, so file the appeal first.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
- 29 CFR 2560.503-1, claims procedure
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 45 CFR 147.136, internal claims and appeals and external review
- 29 U.S.C. 1024(b)(4), plan documents on request
- 45 CFR 147.130, preventive services
- 29 U.S.C. 1185b, Women's Health and Cancer Rights Act
- 42 U.S.C. 300gg-27, Women's Health and Cancer Rights Act for individual coverage
Sources
- 29 CFR 2560.503-1, claims procedure
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 45 CFR 147.136, internal claims and appeals and external review
- 29 U.S.C. 1024(b)(4), plan documents on request
- 45 CFR 147.130, preventive services
- 29 U.S.C. 1185b, Women's Health and Cancer Rights Act
- 42 U.S.C. 300gg-27, Women's Health and Cancer Rights Act for individual coverage
Denial reasons this answers
- Denial reason
Not a covered benefit
The plan says your policy does not cover this service. Read the exact exclusion, check whether the service really falls inside it, and check whether a law requires the plan to cover it anyway.
- Denial reason
Cosmetic
Your plan says the surgery or treatment is meant to change how you look, not to treat a medical problem. The fight is usually over whether it treats a real medical or functional problem, and over the plan's own definition of cosmetic.
- Denial reason
Custodial care
Your plan says the nursing, home health or facility care you get is help with daily living, not skilled medical care. If skilled staff are doing the work, you can challenge the label, and Medicare does not require that you are improving.
- Denial reason
Dental or vision boundary
Your medical plan says the care belongs to your dental or vision plan, and the dental or vision plan may say it belongs to medical. Get both answers in writing and compare each to the plan's own wording.
- Denial reason
Visit or benefit limit reached
Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.