GetMyYes

A sample appeal packet, opened up

FICTIONAL DEMONSTRATION · NOT A REAL PERSON OR PLAN · UPDATED JULY 2026

This is an illustrative sample, not a promised result. “Jordan Lee,” “Example Health Plan,” all identifiers, dates, treatments, and facts below are invented. A real packet is based only on the denial and answers supplied by its user, must be reviewed before sending, and cannot guarantee approval.

Case summary

  • Member: Jordan Lee · Member ID: SAMPLE-0001
  • Plan: Example Health Plan
  • Denied request: Example Treatment, prior authorization
  • Stated reason: plan says two preferred alternatives must be tried first
  • Appeal route: internal appeal using the address and deadline printed on the fictional notice

1. Appeal letter

Re: Request for reconsideration of prior-authorization denial

I am asking Example Health Plan to reconsider its denial of Example Treatment. The notice states that two preferred alternatives must be tried first. My prescribing clinician’s records should be reviewed because Alternative A was previously ineffective and Alternative B is not appropriate for the documented circumstances described in the attached clinician statement.

Please review the attached records against the plan criteria cited in the denial, provide the criteria used, and send a written decision with the next level of appeal rights. This request does not add facts beyond the supporting records.

2. Evidence checklist

  • Copy of the denial notice and appeal-rights page
  • Clinician statement addressing each stated requirement
  • Relevant treatment-history records for Alternative A
  • Documentation explaining why Alternative B is inappropriate
  • Plan criteria or formulary page referenced by the denial
  • Copies only; keep the originals and proof of submission

3. Clinician letter request

Please confirm the requested treatment, explain why it is appropriate, address each alternative named by the plan, identify the records supporting those statements, and state whether delay creates urgency. Please avoid adding facts that are not in the medical record.

4. Insurer call script

  1. Confirm the exact appeal deadline, destination, and accepted submission methods.
  2. Ask which plan criterion controlled the denial and request a copy.
  3. Ask whether a peer-to-peer review is available without waiving formal appeal rights.
  4. Record the representative’s name, call reference number, date, and time.

5. Submission cover sheet

Subject: Internal appeal · SAMPLE-0001 · Example Treatment. The fictional packet lists every enclosure and requests written confirmation of receipt. A real cover sheet uses the destination printed on the user’s own denial notice, never a generic address.

6. Deadline tracker

  • Denial-notice date: SAMPLE DATE
  • Deadline shown on notice: VERIFY FROM YOUR LETTER
  • Submitted: record date, method, and confirmation number
  • Expected response: confirm directly with the plan

7. Follow-up plan

If the insurer asks for missing information, answer only with verified records. If it upholds the denial, read the final determination for the next internal level or independent external-review instructions. Urgent cases may follow different timing.