Letter of medical necessity (for your clinician to adapt)
A letter in your clinician's voice that explains the diagnosis, what has been tried, why the denied care is medically necessary for you, and what is likely to happen without it. Every clinical statement is a blank for the clinician to complete.
- Private: nothing leaves this tab
- A template, not legal advice
When to use this, and what it is not
When to use this. How to hand this to the office: print it or save it with the blanks showing, clip your denial letter to it, and ask the clinician to fill in every clinical blank from your chart, edit it in their own words, and sign it. You fill in only the plan details. The wording is a starting point for the clinician, who decides what is accurate for you. Use it for a not-medically-necessary denial, alone or with your appeal letter.
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]
14 November 2026
[Name and address of the plan's medical reviewer]
Re: Letter of medical necessity (for your clinician to adapt) Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am [The clinician's name], [The clinician's credentials]. I treat [The patient's full name] (member ID [Member ID]) as a specialist in [The clinician's specialty], and I have cared for this patient since [How long the clinician has treated the patient]. I am writing in support of the appeal of [Name of the health plan]'s decision of [Date on the denial notice], claim or reference [Claim or reference number], to deny [The care or drug that was denied].
Diagnosis: [Diagnosis]
Relevant history and current condition: [Relevant history and current condition]
Treatments already tried and the results: [Treatments already tried and what happened]
Why the requested service is medically necessary for this patient: [Why the denied service is medically necessary for this patient]
What I expect to happen without it: [What is likely to happen without it]
Supporting evidence: [Supporting evidence]
The denial gave this reason: [The reason the denial gives]. My response to that reason: [The clinician's response to that reason]
I ask that the denial be overturned. I ask that this letter and the enclosed records be placed in the claim file and considered in full. Because the decision rests on a medical judgment, I also ask that the review be done by a health care professional with training and experience in [The clinician's specialty] who was not involved in the first decision.
I am available to speak with the reviewing physician at [A phone number where the reviewer can reach the clinician].
Enclosures: 1. Copy of the denial letter 2. Relevant chart notes, test results and imaging reports 3. Guidelines or studies the clinician cites
Sincerely, [Your name]
Before you send it
The clinician's office can fax or upload it to the plan, or give it to you to include with your appeal. Use the appeals address or fax number on the denial notice; do not guess one. To prove it arrived, use certified mail with a return receipt, a fax confirmation page, or a portal screenshot that shows the date, and keep a copy.
What to enclose
- Copy of the denial letter
- Relevant chart notes, test results and imaging reports
- Guidelines or studies the clinician cites
What happens next
- You: give the letter, the denial letter and this page's instructions to your doctor's office. Ask when it will be ready and write the date down.
- Your clinician: completes the clinical blanks, edits the letter, signs it and sends it to you or to the plan. Ask for it at least a week before your appeal is due.
- You: attach it to your appeal. Your appeal deadline depends on your coverage and is printed on your denial notice. For most job-based and individual plans it is at least 180 days after you receive the notice. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different deadlines, often shorter, and they are on your notice. Check the date on your notice, which controls.
- Plan: the reviewer must consider the comments and records you submit, including material that was not part of the first decision. Keep proof of the date the plan received the letter.
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.