UnitedHealthcare Appeal Letter Template

[Your Name]
[Your Address]
[City, State ZIP]
[Phone Number]
[Email Address]

[Date]

UnitedHealthcare Appeals Department
[Address from denial letter or:]
P.O. Box 30555
Salt Lake City, UT 84130

RE: APPEAL OF CLAIM DENIAL
Member Name: [Your name or patient name]
Member ID: [Your UHC ID number]
Claim Number: [From denial letter]
Date of Service: [Date of denied service]
Provider: [Doctor/facility name]
Date of Denial: [Denial letter date]

Dear UnitedHealthcare Appeals Department:

I appeal the denial of [specific service/treatment] dated [denial date].

[For ERISA plans, add:]
This appeal is submitted pursuant to the Employee Retirement Income Security Act (ERISA) Section 503 and implementing regulations at 29 CFR §2560.503-1. I request a full and fair review of this denial.

[For Medicare Advantage, add:]
This appeal is submitted pursuant to 42 CFR §422.562 and §422.568. [For expedited: "I request expedited review because delay would seriously jeopardize my health or ability to regain maximum function."]

I. FACTUAL BACKGROUND

[Describe your medical condition and why the denied treatment is necessary. Example:]

I am a [age]-year-old [gender] diagnosed with [condition] on [date]. My condition causes [symptoms/functional limitations]. Despite trying [list conservative treatments], my condition has [worsened/not improved].

My physician, Dr. [Name], [specialty], has recommended [denied treatment/service] because [medical reason]. This treatment is medically necessary to [prevent deterioration/improve function/treat condition].

II. WHY THE DENIAL IS WRONG

A. The Denied Service is Covered Under My Plan

My Summary Plan Description states [quote relevant coverage language]. [Denied service] falls within this coverage because [explanation].

B. The Service is Medically Necessary

UnitedHealthcare's own medical policy [policy name/number] defines medical necessity as [quote definition]. My case meets this definition because:

1. [How you meet first criterion]
2. [How you meet second criterion]
3. [Continue for each criterion]

Dr. [Name]'s attached letter explains in detail why [service] is medically necessary for my specific condition. Key points include:

• [Point from doctor's letter]
• [Point from doctor's letter]
• [Point from doctor's letter]

C. Clinical Evidence Supports This Treatment

[Choose relevant evidence:]

• The treatment is recommended by [NCCN/medical society] guidelines (attached)
• Peer-reviewed studies demonstrate efficacy (attached)
• The treatment is FDA-approved for my condition
• This is standard of care for my diagnosis

III. UHC'S DENIAL REASONING IS FLAWED

[Address the specific denial reason. Choose appropriate section below:]

[If denied as "not medically necessary":]
UHC claims the service is "not medically necessary," but this conclusion is contradicted by:

• My treating physician's clinical judgment
• Documented failure of alternative treatments
• Clinical guidelines supporting this treatment
• My individual circumstances requiring this specific intervention

UHC's reviewer, who has never examined me, cannot override my treating specialist's medical judgment without specific clinical evidence—which UHC has not provided.

[If denied as "experimental/investigational":]
UHC incorrectly labels this treatment as "experimental." However:

• FDA approved [drug/device] for [indication] on [date]
• [NCCN/medical society] guidelines recommend this treatment (Category [X])
• Peer-reviewed studies demonstrate efficacy (attached)
• This is widely accepted medical practice, not experimental

[If NaviHealth/AI denial for rehab/SNF:]
UHC's denial appears to be based on the NaviHealth algorithm rather than individualized medical assessment. This automated system:

• Has been the subject of multiple lawsuits alleging systematic over-denials
• Is currently under investigation by CMS
• Cannot account for my individual circumstances
• Should not override my physician's clinical judgment

I request that a physician—not an algorithm—review my case considering:

• My home environment: [stairs/no caregiver/safety concerns]
• My functional limitations: [specific ADL dependencies]
• My ongoing therapy needs: [specific skilled services required]
• My individual complications: [comorbidities/setbacks]

[If emergency care denied as out-of-network:]
Federal law and my plan require coverage of emergency care regardless of network status. UHC's denial violates:

• The Prudent Layperson Standard: My symptoms ([chest pain/severe bleeding/etc.]) warranted immediate emergency care
• The Emergency Medical Treatment and Labor Act (EMTALA)
• My plan's emergency coverage provisions

The determination of "emergency" must be based on my symptoms at the time I sought care, not the final diagnosis after tests.

IV. SUPPORTING DOCUMENTATION

I am submitting the following documents in support of this appeal:

1. Letter from Dr. [Name] dated [date] explaining medical necessity
2. Medical records documenting my condition and treatment history
3. [Clinical guidelines/NCCN recommendations]
4. [Peer-reviewed studies supporting treatment]
5. [Failed alternative treatment documentation]
6. [Any other relevant evidence]

[For ERISA plans, add:]
Pursuant to 29 CFR §2560.503-1, I request access to:

• All documents, records, and other information relevant to my claim
• The specific medical policy or guideline UHC relied upon
• Any internal rules, guidelines, or protocols used to make this determination
• Identification of medical or vocational experts whose advice was obtained

V. CONCLUSION

For the reasons stated above, UnitedHealthcare's denial of [service/treatment] is incorrect. The service is:

• Covered under my plan
• Medically necessary as determined by my treating physician
• Supported by clinical evidence
• Appropriate for my condition

I respectfully request that UnitedHealthcare reverse its denial and approve coverage for [service/treatment].

[For ERISA plans, add timeline:]
I expect a written response within [30 days for standard/72 hours for urgent] as required by ERISA regulations.

[For Medicare Advantage, add:]
I expect a decision within [30 days for standard/72 hours for expedited] as required by Medicare regulations. If UHC upholds the denial, I request immediate forwarding to the Independent Review Entity for external review.

Please send all correspondence regarding this appeal to the address above.

Thank you for your prompt attention to this matter.

Sincerely,

[Your signature]
[Your printed name]

Enclosures: [List each attachment]

cc: [Your doctor's name, if appropriate]
[Your attorney, if applicable]