Sample appeal packet: a denied physical therapy claim

October 12, 2026

Jordan Testcase
Jordan Testcase
12 Fictional Road
Testville, OH 43000

EVERGREEN TEST HEALTH PLAN
Evergreen Test Health Plan, Appeals Department, PO Box 000, Testville, OH 43000

RE: Appeal of denial — Outpatient physical therapy, 12 sessions
Member ID: TST-998877
Claim number: CLM-TEST-44521
Date of denial: September 2, 2026

I am appealing the denial of my claim CLM-TEST-44521 for Outpatient physical therapy, 12 sessions, which Evergreen Test Health Plan denied on 2026-09-02. The service date was 2026-08-14. I am asking that this decision be reversed.

The denial states: "The service is not medically necessary based on the information we received." I disagree with this conclusion, and I answer it as follows.

First, the denial says it relied on "the information we received." It does not say what information was reviewed or what was missing. I ask Evergreen Test Health Plan to identify the information it relied on and the specific reason it found the physical therapy not medically necessary for me.

Second, my treating provider is in the best position to explain why this treatment was needed. [PROVIDE: a letter from my doctor or physical therapist explaining why these 12 physical therapy sessions are medically necessary for me]

Third, the denial does not address my condition or my symptoms. [PROVIDE: my diagnosis and a short description of the symptoms or functional limits that the physical therapy was meant to treat, as documented by my doctor]

Fourth, the denial does not address my treatment history or my response to care. [PROVIDE: the dates of my physical therapy visits, any earlier treatments I tried, and the progress or improvement my provider recorded]

Because the denial was based on the information the plan received, any gap in that information should be corrected by the records I am submitting with this appeal. I ask that the plan review them in full.

I also understand my rights regarding external review. Under 45 CFR 147.136(c), if a State external review process applies to and is binding on a health insurance issuer offering group or individual health insurance coverage and includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the issuer must comply with the applicable State external review process. My plan is an individual plan. I reserve my right to pursue external review if this appeal is not resolved in my favor.

I request that Evergreen Test Health Plan reverse its denial and approve Outpatient physical therapy, 12 sessions. I also request the plan's written explanation of the specific information and criteria it used to decide that this service was not medically necessary.

Please send me a written response to this appeal.

Sincerely,

Jordan Testcase

cc: Ohio Department of Insurance

Enclosures:
- Copy of the denial letter
- Letter of medical necessity from my doctor
- Medical records showing my diagnosis, symptoms, and treatment history
- Physical therapy visit records and progress notes

What's in this packet.

Appeal-Letter.docx: the appeal letter, editable.

Appeal-Letter.pdf: the same letter.

Next-Steps.pdf: this sheet.

Before you send.

• Add: a letter from my doctor or physical therapist explaining why these 12 physical therapy sessions are medically necessary for me
• Add: my diagnosis and a short description of the symptoms or functional limits that the physical therapy was meant to treat, as documented by my doctor
• Add: the dates of my physical therapy visits, any earlier treatments I tried, and the progress or improvement my provider recorded
• Obtain and attach a letter from your treating provider or physical therapist explaining why these 12 physical therapy sessions are medically necessary.
• Attach documentation showing your specific diagnosis and details about your symptoms or functional limitations.
• Gather and include physical therapy visit records, prior treatment history, and progress notes showing your improvement.

Where to send it.

Send your appeal to:

Evergreen Test Health Plan, Appeals Department, PO Box 000, Testville, OH 43000

Insurer phone: 1-800-555-0100

Your deadline.

Your denial letter says: "180 days of the date of this letter"

Send a copy to.

• Ohio Department of Insurance
  https://insurance.ohio.gov/
  Phone: 800-686-1526

If your appeal is denied again.

"Health Coverage and External Review Appeals Process | Department of Insurance" (https://insurance.ohio.gov/about-us/complaint-center/health-coverage-external-review-process)

"(c) State standards for external review—(1) In general. (i) If a State external review process that applies to and is binding on a health insurance issuer offering group or individual health insurance coverage includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the issuer must comply with the applicable State external review process and is not required to comply with the Federal external review process of paragraph (d) of this section. In such a case, to the extent that benefits under a group health plan are provided through health insurance coverage, the group health plan is not required to comply with either this paragraph (c) or the Federal external review process of paragraph (d) of this section." (45 CFR 147.136(c))

Keep a record.

Send by a trackable method, keep copies, and note who you spoke to.