[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-279705-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-279705-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","medical-appeals-toolkit-sample-letter-for-a-not-medically-necessary-and-investigational-appeal","Medical Appeals Toolkit - Sample Letter for a Not Medically Necessary and Investigational Appeal","","A sample appeal letter template addressing an insurance denial for Bilateral Digital Breast Tomosynthesis and a screening mammogram based on claims of “not medically necessary” and “investigational.” The letter explains the ordered services, cites the denial rationale tied to insufficient evidence, and frames why payment should be approved. It includes placeholders for member and claim details, requests review of supporting documents such as physician letters, medical policy, scientific articles, visit notes, and the patient’s statement, and asks the insurer to contact the appeals department if more information is needed.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medical-appeals-toolkit-sample-letter-for-a-not-medically-necessary-and-investigational-appeal/279705/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-appeals-toolkit-sample-letter-for-a-not-medically-necessary-and-investigational-appeal/279705.png","ImageObject",442,249,{"name":42,"@type":43},"eBook King","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What denial reasons does the sample letter address?","Question",{"text":63,"@type":64},"It addresses insurance denials stating the procedure is “not medically necessary” and “investigational” due to insufficient evidence in the medical literature.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which medical services does the letter reference?",{"text":68,"@type":64},"It references Bilateral Digital Breast Tomosynthesis ordered by the doctor along with a screening mammogram and consideration of the patient’s family history.",{"name":70,"@type":61,"acceptedAnswer":71},"What supporting materials does the letter ask to include for review?",{"text":72,"@type":64},"It lists a physician letter on medical necessity, the insurer’s corporate medical policy and scientific articles, office chart notes, and a patient statement explaining medical necessity.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},279705,1790178770,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,113,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":115,"slug":116},18,30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Sample letter for a “not medically necessary” and “investigational” denial  \nSituation:  \nYour doctor has ordered a Bilateral Digital Breast Tomosynthesis, a screening mammogram, given your family history of breast cancer. Your insurance company denied the test as being not medically necessary and investigational (experimental) because there is insufficient evidence in the medical literature to show that this procedure can improve the sensitivity, specificity or overall accuracy of breast cancer detection, above and beyond that achieved without this technology. You have decided to appeal your insurer’s denial of payment.  \n[Your name, address]  \n[Member Policy Identification Number][Appeal Identification Number]  \n[Date you are writing this appeal]  \n[Contact information for your insurer’s appeals department] To whom it may concern:  \nI’m appealing your company’s decision to deny payment for the Bilateral Digital Breast Tomosynthesis ordered by my doctor, and that I received on 3/14/13 – Claim No. 2596BG. The reason listed on the denial notice is “NOT MEDICALLY NECESSARY.” Additionally, under your clinical rationale, you further state that based on the insurance company’s criteria that Digital Breast Tomosynthesis is considered investigational.  \nAttached to this letter you will find the following supporting documents as to why this claim should be paid.  \n• A letter from my physician stating why he found it medically necessary for me to have this procedure.  \n• The insurer’s corporate medical policy (CPR) for Bilateral Digital Breast Tomosynthesis and recent scientific articles to show this is standard of care for my health and family history.  \n• The chart notes from my office visit.  \n• My statement outlining why I believe the procedure was medically necessary.  \nPlease let me know if you need any other information to review my case (via phone: 123- 555-7890) .  \nI look forward to rectifying this outstanding bill in a timely manner.  \nSincerely,  \n[Your name]  \n[Your phone number]","cbCaiaDyz7Vgo2m6","https://ap.wps.com/l/cbCaiaDyz7Vgo2m6","pdf",70952,"English","# Appeal Letter Overview\n# Case Details and Denial Basis\n# Supporting Documents Checklist\n# Closing and Contact Request","[{\"question\":\"What denial reasons does the sample letter address?\",\"answer\":\"It addresses insurance denials stating the procedure is “not medically necessary” and “investigational” due to insufficient evidence in the medical literature.\"},{\"question\":\"Which medical services does the letter reference?\",\"answer\":\"It references Bilateral Digital Breast Tomosynthesis ordered by the doctor along with a screening mammogram and consideration of the patient’s family history.\"},{\"question\":\"What supporting materials does the letter ask to include for review?\",\"answer\":\"It lists a physician letter on medical necessity, the insurer’s corporate medical policy and scientific articles, office chart notes, and a patient statement explaining medical necessity.\"}]","Medical Appeals Toolkit - Sample Letter for a Not Medically Necessary and Investigational Appeal | PDF",1789525816]