Adverse Benefit Determination: Medical Necessity Denial

This letter informs the member that a claim or pre-authorization request has been denied because the service was determined not to be medically necessary or is considered experimental/investigational.

Letter Template

Date: {{current_date}}

Member Name: {{member_name}} Member ID: {{member_id}} Claim Number: {{claim_number}} Date of Service: {{date_of_service}} Provider: {{provider_name}}

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1. The Decision

We have reviewed your claim for {{cpt_code}} (Diagnosis: {{diagnosis_code}}) and have determined that this service is not covered under your health plan. This decision is a full denial of the requested benefit.

2. Clinical/Factual Basis

Our medical review team, including board-certified specialists, reviewed the clinical documentation submitted by {{provider_name}}. The review found that the requested service, {{cpt_code}}, was intended to treat {{diagnosis_code}}. However, the documentation provided does not demonstrate that the patient met the clinical criteria required for this specific intervention at this time.

3. Plan Provision / Clinical Guideline

This determination was made in accordance with Section {{policy_section}} of your Summary Plan Description (SPD), which defines "Medically Necessary" services. Specifically, we referenced Clinical Policy Bulletin #{{cpb_number}}, which states that for {{cpt_code}} to be considered medically necessary, the patient must first fail conservative therapy for a period of at least six months.

4. Rationale (The "Why")

While we understand that {{provider_name}} recommended this service, our review of your medical records indicates that you have only completed three months of conservative therapy. Therefore, the requested service is considered premature and does not meet the plan's definition of medical necessity as it is not the least intensive or most appropriate level of service required for your condition at this stage.

5. Appeal Rights

You have the right to appeal this decision. If you or your provider disagree with our determination, you may submit a written request for an internal appeal within 180 days of receiving this notice. Please include any additional medical records or supporting documentation that you would like us to consider.

Internal Appeal Address: Health Plan Appeals Department P.O. Box 12345 City, ST 12345

If the internal appeal is upheld, you may also be eligible for an External Review by an independent review organization (IRO). For more information, please contact the Member Services number on the back of your ID card.