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Appeal letter templates

Appeal letter template: GLP-1 denied as "not medically necessary"

For appealing a denial that claims the medication isn't medically necessary. Appeals succeed more often than people expect — most plans must respond within 30 days, and you have the right to an external review if the internal appeal fails.

Template, not legal or medical advice. Square brackets mark what you (or your clinician) fill in. Clinical claims must come from your own prescriber and records — this page just saves you the blank-page problem. 
[Date]

[Insurance company name]
Appeals Department
[Address from your denial letter]

RE: Appeal of denial — claim/reference #[number]
Patient: [Patient name], DOB: [DOB], Member ID: [ID]
Medication: [Drug name]

To whom it may concern:

I am appealing your denial dated [date] of [drug name], which was denied as not medically necessary. I ask that you reverse this determination for the following reasons:

1. My diagnosis of [condition] is documented in the attached records from [prescriber name].
2. [Drug name] is FDA-approved for exactly this indication.
3. I have tried the alternatives your policy prefers: [list drugs/programs, dates, outcomes or intolerances]. They [failed to achieve / caused].
4. My prescriber's letter (attached) details why this medication is appropriate, citing [clinical guideline, e.g., ADA Standards of Care / FDA labeling].
5. Untreated, my condition presents documented risks: [complications relevant to your case].

Enclosed: denial letter, prescriber letter of medical necessity, relevant records and lab results.

If this appeal is denied, please provide the clinical criteria used, the credentials of the reviewer, and instructions for external review, as required by my plan and applicable law.

Sincerely,
[Your name, contact information]

How to use this template

  1. Copy it (button above) and fill every [bracket] with your details.
  2. Bring it to your prescriber — the clinical justification must be theirs, drawn from your records.
  3. Send via the method on your denial letter or your plan's PA fax/portal, and keep a dated copy.
  4. Use our cost calculator while you wait — cash-pay options may bridge the gap.