Insurance Denial Appeal Letter Writer
Turns a denial notice and the therapist's treatment notes into a clear, organized appeal letter the clinic can send to the insurance company.
Before and after
Cedarstead Physical Therapy
4247 Aspenstead Rd, Fairhaven
330-555-0134
Northline Health Appeals
PO Box 4410
RE: Appeal of claim denial
Patient: Ivy Carver
Member ID: W5530917
Claim number: NH-882041
Dates of service: 3/4 to 3/25 (visits 9 through 14)
Denial letter dated: 4/2
To the Appeals Reviewer:
Cedarstead Physical Therapy is appealing the denial of visits 9 through 14 for Ivy Carver. We ask that the denial be reversed and these visits be covered.
Your letter states the reason for denial as "services not medically necessary, no measurable progress documented." We respectfully disagree, and our treatment notes show measurable progress.
Ms. Carver is being treated after a right rotator cuff repair. At her start of care on 1/20, her right shoulder flexion was 85 degrees and abduction was 70 degrees. She could not reach an overhead shelf or dress herself without help. Her QuickDASH score was 68.
Her measurements have improved at each reassessment:
- Visit 8 (3/3): flexion 120 degrees, abduction 105 degrees, QuickDASH 52
- Visit 14 (3/25): flexion 138 degrees, abduction 122 degrees, QuickDASH 41
Between visit 8 and visit 14, the visits you denied, her flexion improved by 18 degrees, her abduction improved by 17 degrees, and her QuickDASH score dropped by 11 points. Since the start of care, flexion has improved by 53 degrees and abduction by 52 degrees.
Her goals are right shoulder flexion of 160 degrees and a QuickDASH score under 25 so she can return to work stocking shelves. She has not yet reached these goals. She has attended every scheduled visit. In our clinical judgment, continued skilled physical therapy is needed, and we recommend it.
We request that Northline Health cover visits 9 through 14 for dates of service 3/4 to 3/25 and reverse the denial.
Enclosures:
- Referral from Dr. Hamid Nasser
- Progress notes
Please contact our clinic at 330-555-0134 with any questions.
Sincerely,
Jacqueline Desai, PT, DPT
Cedarstead Physical Therapy
Before you send: The appeal deadline was not provided. Check the denial letter for the deadline and send the appeal securely, using the method your clinic uses for patient records. Confirm appeal rights and requirements with Northline Health or a billing or legal professional.
Questions for the owner
- What is the appeal deadline listed on the denial letter?
- What date should appear on the letter?
- Should the appeal include the diagnosis or procedure codes? If so, please provide them.
What it does
Turns a denial notice and the therapist's treatment notes into a clear, organized appeal letter the clinic can send to the insurance company. It uses only the facts the clinic provides and flags what is still missing.
Use it when: Use when a physical therapy clinic needs to write an insurance denial appeal letter from a denial notice and the treatment notes, such as: write an appeal for this denial, fight this denial, or insurance denied our visits.