The sample letter is meant to be be used as a starting point if you are denied a service, procedure or treatment because the insurer says it is "not medically necessary." Feel free to modify it for your particular situation.

You will notice there is reference in the letter to both state mandated coverage and to a regulatory agency. If you don't know the law of your state or the regulatory agency, go to The Actors' Fund Of America's Health Insurance Resource Center (www.ahirc.org , click on your state, then click on "Insurance Guides" and/or Complaints/Appeals). If you have difficulty, contact your Department of Insurance. They can guide you. To locate contact information for your state insurance department, see: www.naic.org . Click on "NAIC States and Jurisdictions."

There is reference in the sample to two situations: an appeal with urgency due to the need for speed or a regular appeal. If there is any question whether the need is urgent, err on the side of requesting an urgent response.

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