Insurance Appeal (Internal)

SAMPLE — not a real letter. Names, amounts, and account numbers are fictional.

April 3, 2026 Jordan Sample 123 Sample Street Anytown, ST 00000 Cascade Mutual Insurance Appeals Department P.O. Box 0002 Sampleville, ST 00002 RE: Internal appeal of claim denial — Member ID MEM-0000-SAMPLE; Claim CLM-0000-SAMPLE; date of service March 3, 2026; MRI lumbar spine without contrast (CPT 72148); billed $1,870.00 Dear Appeals Department: I am appealing the denial of the claim above. Your Explanation of Benefits dated March 24, 2026 denies the claim with reason code SAMPLE-50, "service not medically necessary." I request that this decision be reviewed and reversed, and the claim reprocessed for payment under my plan. The MRI was ordered by my treating physician, Dr. Alex Example, after six weeks of conservative treatment failed to resolve my symptoms. My records, enclosed, document: low back pain radiating into the left leg beginning January 2026; a course of physical therapy from January 12 to February 20, 2026; prescribed anti-inflammatory medication; and, at the February 24 visit, new numbness in the left foot and a diminished reflex noted on examination. Dr. Example ordered the MRI to evaluate for nerve root compression and to determine whether a referral for injection or surgical consultation was warranted. This is the sequence the American College of Radiology Appropriateness Criteria for low back pain describe as appropriate for imaging: persistent symptoms after a trial of conservative therapy, together with radicular findings on examination. The service was not elective and not for screening; it was ordered because the clinical picture changed. Please provide, with your determination, the specific clinical criteria or guideline your reviewer applied, and the name and credentials of the reviewing clinician. If the denial is upheld, I understand I have the right to request an independent external review under the Affordable Care Act, and I intend to exercise it. I request a written determination within the timeframe that applies to a post-service internal appeal under my plan. Please send it to the address above. Sincerely, Jordan Sample Enclosures: EOB dated March 24, 2026; letter of medical necessity from Dr. Alex Example; physical therapy discharge summary; office visit notes of January 5, February 3, and February 24, 2026