What must be included in the appeals letter?

In crafting an appeals letter to an insurance company, it is essential to clearly articulate what you are asking the insurance company to do. This includes detailing the specific action you want the insurer to take regarding the prior authorization denial, such as approving coverage for a medication, procedure, or service. By specifying the request, you provide the reviewer with a clear understanding of the objective of the appeal, which is crucial for facilitating a decision in your favor.

While including a detailed history of the patient's condition, the specific medication requested, and names of healthcare providers can enhance the context and support the case, the primary focus of the appeals letter needs to be on the actionable request. This clarity helps in streamlining the review process and makes it easier for the insurance company to address the appeal.