Read an actual appeal letter, start to finish.

[PRACTICE LETTERHEAD]
[DATE]

VIA PAYER APPEALS PORTAL AND CERTIFIED MAIL
[PAYER NAME] — Appeals & Grievances Department
[APPEALS ADDRESS]

RE: First-Level Provider Appeal — Request for Reconsideration and Payment
Member: [MEMBER NAME] · ID: [MEMBER ID]
Claim: [CLAIM #] · DOS: [DATES OF SERVICE]
Provider: [PROVIDER / NPI] · Denial: CARC CO-50

Dear Appeals Reviewer:

This is a formal first-level appeal of the denial of CPT 97110 (therapeutic exercise, 4 units) for the above dates of service, denied under CARC CO-50 as “not medically necessary.” We request reconsideration and payment of [BILLED AMOUNT].

The denial misapplies the plan's own coverage criteria. Your published medical policy for outpatient rehabilitative therapy, [POLICY # / TITLE / VERSION], provides coverage where the member exhibits a functional deficit, services require the skills of a licensed therapist, and documented progress toward measurable goals is expected. The enclosed initial evaluation documents [OBJECTIVE FINDINGS — e.g., ROM limitation, strength grade, functional outcome score], establishing precisely the deficit your policy describes. Daily treatment notes (Enclosure 3) document skilled interventions and objective, measured progress at each visit.

The determination letter identifies no specific criterion that the documentation fails. A blanket assertion of non-necessity, without engagement with the clinical record, does not satisfy the plan's obligation to provide the specific reason for an adverse determination, the criteria relied upon, and the clinical rationale. We request that, if this appeal is not approved in full, the plan identify the specific policy criterion at issue and produce the internal rule, guideline, or protocol relied upon, as required for a full and fair review under applicable law, including 29 C.F.R. § 2560.503-1 for ERISA-governed plans.

Requested action. Reverse the denial and issue payment of [BILLED AMOUNT] within the timeframe required by the plan and applicable state law. Please issue a written determination; absent timely resolution, we reserve all rights to second-level review and independent external review.

Enclosures:
1. Denial determination / EOB  2. Initial evaluation & plan of care (physician-certified)  3. Daily treatment notes for all DOS  4. Physician referral  5. Relevant excerpt of [PAYER POLICY]

Respectfully,
[SIGNER NAME, CREDENTIALS]
[PRACTICE NAME · PHONE · EMAIL]