Medical Insurance Claim Appeal

Claim No.:_________________________

Name of Policy Holder: ______________________________

Policy ID No.: _____________________________________

Dear _______________,

On December 1, you denied my insurance claim for chelation treatment on the grounds that it was alternative treatment and therefore not medically necessary. However, I believe that your reviewer was missing several key facts. As these have been added, updated or highlighted in the attached forms, I would like to request that you review my case again.

In brief, chelation is supported as a valid and approved medical treatment against heavy metal poisoning. As you can see in the attached copies of my previous medical records, I was diagnosed with mercury poisoning in 2009 and have suffered many symptoms, including retinal detachments in both eyes. The chelation has been approved by my general physician as an offensive measure against further symptoms.

Please provide me with the name and identification number of the reviewer assigned so that I may send the necessary information as soon as possible. It is my firmest belief that these treatments constitute a real and pressing medical need.

I look forward to hearing from you within the next 14 days. Thank you for your time and consideration.

Sincerely,