How to write a prior authorization appeal letter (template inside)

A good appeal doesn't argue that the patient needs the service. It shows, point by point, that the request already meets the payer's own criteria.

Before you write

• Read the denial reason word for word. Your whole letter answers it.
• Get the policy the decision relies on. Ask for it if it isn't cited. You'll quote it back.
• Find the deadline on the denial notice. Appeal windows vary by plan type and payer.
• Consider a peer-to-peer review. A ten-minute call with the medical director sometimes resolves it faster than a letter.

The structure

1. Identifiers: patient name, date of birth, member ID, reference or claim number, date of the denial.
2. The request: the service, with CPT/HCPCS and ICD-10 codes, and a one-line ask to overturn.
3. The criteria: quote the specific policy language the denial relied on.
4. The evidence: one short paragraph per criterion, with dates, results, and where it's documented.
5. The stakes: what delay means clinically for this patient.
6. The close: request reversal, offer a peer-to-peer, list attachments, and sign.

Template

[Date]

[Payer name] · Appeals / Utilization Review
Re: Appeal of denial for [service], CPT [code]
Patient: [name] · DOB [date] · Member ID [ID]
Reference #: [number] · Date of denial: [date]

I am writing to request reconsideration of the denial of
[service] for my patient, [name]. The denial states:
"[quote the denial reason]".

Your policy [policy name/number] states that [service] is
indicated when "[quote the criterion]". My patient meets
this criterion:

• [Criterion 1]: [evidence with dates, e.g. completed 8 weeks
  of physical therapy, Mar 2 – Apr 27, without improvement]
• [Criterion 2]: [objective findings, e.g. positive straight-
  leg raise at 40°, diminished left ankle reflex]
• [Criterion 3]: [how the result will change management]

Delaying [service] risks [specific clinical consequence].

I ask that you overturn this decision. I'm available for a
peer-to-peer discussion at [phone].

Attached: [visit notes, therapy records, prior imaging]

Sincerely,
[Name], [credentials] · NPI [number]

If the appeal is denied

Most plans have more than one level of appeal. For many plans, federal rules also give patients a right to an external review by an independent reviewer after internal appeals are exhausted. Medicare Advantage has its own multi-level appeals process. The denial notice should explain the next step and its deadline.

AuthAI drafts letters like this from the chart and the payer's policy, so you start from a near-final draft instead of a blank page.

General information, not legal or billing advice.