Prior Authorization Appeal Letter: Template and Filled Sample

[DATE]

[PAYER APPEALS DEPARTMENT]
[ADDRESS FROM THE DENIAL LETTER, not the claims address]

RE: Appeal of Prior Authorization Denial
Member: [NAME]   Member ID: [ID]   DOB: [DOB]
Authorization/Reference #: [NUMBER]
Denial date: [DATE]   Level of care requested: [LOC]
Requesting provider: [NAME, CREDENTIALS, NPI]

To the Appeals Reviewer:

I am writing to appeal the denial of [SERVICE/LEVEL OF CARE]
for the member above. The denial letter dated [DATE] states:

  "[QUOTE THE DENIAL REASON VERBATIM, word for word.]"

We believe this determination is inconsistent with the plan's
own medical-necessity criteria for the following reasons:

1. [CRITERION THE PLAN CITES]: The clinical record shows
   [SPECIFIC FINDING WITH DATE AND SOURCE DOCUMENT]. This
   directly satisfies [POLICY SECTION / ASAM DIMENSION].

2. [SECOND CRITERION]: [FINDING, DATE, SOURCE]. Note that
   [E.G., THE DENIAL APPEARS TO RELY ON INFORMATION THAT WAS
   NOT IN THE SUBMITTED RECORD / AN OUTDATED POLICY VERSION].

3. [RISK OF THE DENIED ALTERNATIVE]: Treatment at [LOWER
   LEVEL OF CARE] was [ATTEMPTED ON DATES / CLINICALLY RULED
   OUT BECAUSE], as documented in [SOURCE].

Requested remedy: approval of [SERVICE] at [LEVEL OF CARE]
for [UNITS/DAYS] beginning [DATE].

Under the plan's appeal procedures and applicable law, we
request a decision within [TIMEFRAME FROM THE DENIAL LETTER].
If this appeal is denied in whole or part, please provide the
specific criteria relied upon, the credentials of the
reviewer, and instructions for [PEER-TO-PEER / EXTERNAL
REVIEW].

Enclosures:
  [ ] Denial letter        [ ] Treatment plan
  [ ] Clinical notes [DATE RANGE]
  [ ] Medical-necessity letter from [CLINICIAN]
  [ ] Relevant policy excerpt [SECTION]

Sincerely,
[NAME, TITLE, CONTACT]

NOTE BEFORE SENDING: verify the appeal deadline on the denial
letter TODAY and calendar it. Send by a trackable method. Log
the submission in your authorization tracker.

ILLUSTRATIVE SAMPLE: fictional member, program, plan, and
dates. Replace every detail with your own record and quote
your payer's current guideline exactly.

September 8, 2026
Sent via Example Health Plan provider portal (appeal upload),
confirmation EX-448201

Example Health Plan, Behavioral Health Appeals
[Address exactly as printed on the denial notice]

RE: Standard first-level appeal of continued-stay denial
Member: Jordan Sample      Member ID: XEH000000000
Denial reference: UM-2026-000000   Denial dated: 9/2/2026
Service: Mental health intensive outpatient program (IOP),
  S9480 per diem, 3 hours/day, 3 days/week
Dates requested: 9/3/2026 through 9/23/2026 (9 program days)
Program: Harbor Point Behavioral (fictional), NPI 0000000000

To the Appeals Reviewer:

We request reconsideration of the September 2, 2026 decision
denying continued IOP for the dates above. The notice states:
  "Member's symptoms have improved and can be safely treated
   at a lower level of care (routine outpatient)."

This appeal answers that reason with dated documentation.

1. Symptoms have not stabilized enough for routine outpatient.
   PHQ-9 was 22 at admission on 8/11 and 17 on both 8/29 and
   9/1 (Exhibit B, pp. 3-4). The treatment plan's step-down
   target is a score under 10 held for two weeks
   (Exhibit C, p. 2).

2. The lower level of care was tried recently and did not hold.
   The member stepped down to weekly outpatient therapy in June
   and returned to IOP on 8/11, after an emergency department
   visit on 8/9 and two missed workdays (Exhibit D).

3. The plan's own continued-stay guideline is met.
   [Plan guideline name, section, version]: "[criterion quoted
   exactly from the current guideline]." The record addresses
   it: [finding, date, exhibit and page].

4. Treatment is active and has a defined end point.
   A medication change on 8/27 needs monitoring through at
   least 9/17 (Exhibit B, p. 6). The discharge plan names the
   outpatient therapist and first appointment (Exhibit C, p. 4).

Requested remedy: approve IOP (S9480) for 9 program days,
9/3/2026 through 9/23/2026, with the next concurrent review
on 9/23/2026.

If any part of this appeal is denied, please send the specific
guideline and criteria relied on, the reviewer's credentials,
and the next appeal or external-review option and deadline.

Enclosures:
  A. Denial notice dated 9/2/2026 (2 pp.)
  B. Progress notes and PHQ-9 scores, 8/11-9/1 (8 pp.)
  C. Treatment plan and discharge plan (5 pp.)
  D. Emergency department visit summary, 8/9/2026 (2 pp.)
  E. [Plan] continued-stay guideline excerpt, [version]

Clinical attestation: I have reviewed the clinical statements
in this letter against the record.
[Name, credentials], [Title]            Date: [date]

Submitted by: [Name], Utilization Review Coordinator
[Phone]  |  [Secure fax or portal]

AFTER SENDING: save the submitted file and the portal
confirmation, calendar the plan's decision deadline, and log
the appeal in your authorization tracker.