Independent Medical Opinion Request Letter

Pro Tip: Review the official instructions document before starting.

[Month Day, Year]

Re: [Your Case/Reference Number] - Independent Medical Opinion

Dear [Recipient Name or "To Whom It May Concern"],

I am writing to formally appeal the denial of my insurance claim, reference number [claim number], for [name of treatment or service] performed on [date of service] by [provider name].

The claim was denied under reason code [code] with the explanation that [quote the denial reason]. I believe this denial is incorrect because [state why]. The enclosed medical records and physician letter demonstrate that this treatment was medically necessary for my condition.

My treating physician, Dr. [name], has provided a letter (enclosed) explaining why [treatment] was the appropriate course of action for my diagnosis of [condition]. The physician's letter addresses the specific denial reason and includes clinical evidence supporting the medical necessity of this treatment.

I have also enclosed [list supporting documents: medical records, clinical guidelines, peer-reviewed studies] that support the medical necessity of the denied service. These materials demonstrate that [treatment] is the standard of care for [condition] and meets the criteria for coverage under my plan.

I respectfully request that you reverse the denial and process this claim for payment. If additional information is needed, please contact me at [phone] or [email]. I am requesting a response within [30 days or as required by your state's insurance regulations].

I am writing to formally appeal the decision dated [date] regarding [describe the decision: denial, assessment, determination]. My case/reference number is [number].

I disagree with this decision because [state specific reasons]. The enclosed documentation supports my position and addresses the basis for the original determination.

Specifically, the decision failed to consider [describe overlooked evidence or errors]. The attached evidence demonstrates that [state what the evidence shows]. This information was [available at the time of the original decision / is new evidence that was not previously available].

I respectfully request that the [agency/office] review the enclosed evidence and reverse the decision. I am prepared to attend a hearing or provide additional information if needed.

Please confirm receipt of this appeal and provide a timeline for the review process. I can be reached at [phone] or [email] during [hours of availability].

Sincerely,

____________________________________

[Your Full Legal Name, Printed]
[Date of Signature]

Enclosures:

1. [Document 1: name and description]
2. [Document 2: name and description]
3. [Copy of government-issued identification]
4. [Supporting evidence: name and description]

Note: Keep a copy of this letter and every enclosure. You may need to reference them later.