How do you write a medical necessity appeal letter?
Short answer
A strong medical necessity appeal letter states what was denied, then shows from the medical record why the care met the payer's criteria when decisions were made. It uses a short clinical timeline, cites the specific rule or criteria (such as the Two-Midnight Rule or the plan's own policy), answers the denial reason point by point and asks for a specific outcome.
Last reviewed by board-certified physician advisors
What to include
- Patient, claim, date of service and denial reference numbers
- The payer's stated denial reason, quoted
- A short clinical timeline: presentation, key findings, treatment and response
- Which criteria were met, and the rule or policy that applies
- A direct answer to each point in the denial
- The outcome you're asking for, such as payment as inpatient
- A physician signature, with the relevant records attached
The five levels of Medicare appeal
Medicare Advantage plans and commercial payers have their own appeal processes and deadlines, set by regulation and by your contracts.
- 1. Redetermination by the Medicare Administrative Contractor, requested within 120 days
- 2. Reconsideration by a Qualified Independent Contractor, requested within 180 days
- 3. Hearing before an Administrative Law Judge, requested within 60 days, with a minimum amount in dispute
- 4. Review by the Medicare Appeals Council, requested within 60 days
- 5. Judicial review in federal district court
Common mistakes
- Generic templates that don't answer the actual denial reason
- Arguments the medical record doesn't support
- Missed deadlines
- Long letters that bury the key clinical facts
Getting it done faster
Software can now draft the letter from the medical record: pulling out the clinical facts and lining them up against the criteria and citations. A physician should still review and sign every letter. Aerolib Appeals drafts payer-ready letters this way, and Aerolib's physician advisors review the clinical argument.
Key terms
Common questions
Who should sign a medical necessity appeal letter?
A physician, ideally the attending or a physician advisor who reviewed the record. A physician's clinical reasoning carries more weight than an administrative letter.
How long should an appeal letter be?
Usually one to three pages. Keep the clinical argument tight and attach the records rather than copying them into the letter.
Can AI write an appeal letter?
It can draft one from the medical record and the applicable criteria, which saves a lot of time. A physician should review the clinical argument and sign it before it's sent.
Talk with a physician advisor
Tell us about your hospital and we'll set up a call with one of our physician advisors.