HCA 110 Module 8 Writing an Appeal for a Denied Claim Example

Making the Case: A First-Level Appeal of a Denied MRI and the Process Behind It

Student Name

Health Care Administration Program, Aspen University

HCA 110: Insurance and Healthcare Reimbursement

Instructor Name

Month Day, Year

Making the Case: A First-Level Appeal of a Denied MRI and the Process Behind It

An appeal asks a payer to reconsider a denial. Many practices appeal too little, writing off denials they could win, or appeal badly, sending a form letter without evidence. This paper explains the appeal process for commercial plans and Medicare and then presents a first-level appeal letter for a composite medical necessity denial of a knee MRI, written so the reviewer can see quickly why the denial should be reversed.

When to Appeal

An appeal is appropriate when the practice believes the payer decided wrongly, most often for medical necessity, coverage interpretation or a claim processed against the wrong rule. If the denial came from the practice's own error, such as a wrong identifier, a corrected claim is faster. Before appealing, the billing specialist reads the denial reason, the plan's policy on the service and the full record to decide whether the evidence supports reversal. The physician who ordered the service is asked to confirm the clinical facts before the letter is drafted.

Appeal Levels

Appeals proceed through levels. The table outlines them for traditional Medicare and for a typical commercial plan.

Medicare Detail

For traditional Medicare, a redetermination must be requested within 120 days of receiving the initial determination, and each later level has its own deadline and, for the hearing and court levels, a minimum amount in dispute that is adjusted each year (Centers for Medicare & Medicaid Services, 2025). Missing a deadline usually ends the appeal, so the billing office tracks each appeal date in its work queue.

What External Review Shows

Appeals often succeed. In an analysis of 408 external appeals of urological claim denials in New York State from 2019 to 2021, 39.5% of denials were overturned, and appeal volume rose each year (Wei et al., 2022). The finding suggests that many denials would be reversed if practices pursued them, although appeals also delay care and cost staff time.

The Denied Claim

Ms. T., the composite 44-year-old teacher from the benefits verification module, had her knee MRI performed after authorization was requested, but the plan later denied the claim as not medically necessary, stating that conservative treatment had not been tried for six weeks. The record showed eight weeks of physical therapy, anti-inflammatory medication and activity changes, plus exam findings of a positive McMurray test and joint line tenderness suggesting a meniscal tear. The plan's own imaging policy lists these findings after six weeks of failed conservative care as criteria for MRI.

The Appeal Letter

Re: First-level appeal, patient Ms. T., member ID and claim number as listed, date of service as listed, MRI of the right knee without contrast.

We request reconsideration of the denial of this claim for lack of medical necessity. The denial states that six weeks of conservative treatment were not documented. The enclosed record shows that Ms. T. completed eight weeks of physical therapy, from her first visit to her last, with documented progress notes, and took anti-inflammatory medication throughout, without improvement.

On examination, her orthopedic surgeon found joint line tenderness and a positive McMurray test, findings consistent with a meniscal tear. Your plan's advanced imaging policy for the knee lists persistent pain after at least six weeks of conservative treatment with mechanical signs on examination as criteria for MRI. Ms. T. met these criteria on the date of service.

Enclosed are the physical therapy records, the orthopedic consultation note, the medication list and the policy section cited. We ask that the claim be reprocessed and paid. Please contact the billing office at the number below with any questions.

Why This Letter Works

The letter is short, specific and built on evidence. It restates the denial reason, shows that the record contradicts it, matches the clinical findings to the plan's own criteria and lists each enclosure. It avoids emotional appeals and general statements about the patient's suffering, which do not change a coverage decision. It also asks for a specific action: reprocess and pay.

Tracking and Follow-Up

The appeal is logged with the date sent, the method, the deadline for the plan's response and the next-level deadline if denied again. If no response arrives in the plan's stated time frame, the specialist follows up. Won and lost appeals are recorded by reason and payer, which shows which denials are worth appealing and which policies the practice should meet up front. Copies of every page sent are kept with the log, since plans sometimes report that enclosures were never received.

Preventing the Next Appeal

Ms. T.'s denial could have been avoided if the authorization request had included the therapy records. The practice added a checklist to imaging authorization requests listing the documents each plan's policy requires. Because billing and insurance-related work already costs practices a large share of revenue (Tseng et al., 2018), preventing a denial is always cheaper than winning an appeal.

If the Appeal Is Denied

If the plan upholds the denial, the letter explains why and states the next level and its deadline. The specialist reviews the reason, asks the physician whether a peer-to-peer discussion with the plan's medical reviewer would help and decides whether to move to the next level. For commercial plans, external review by an independent organization is often available after internal appeals, and its decision is binding on the plan. Patients should be kept informed, since they may also have their own appeal rights.

Conclusion

A good appeal is a short evidence-based argument that answers the payer's reason for denial using the record and the payer's own policy. The appeal levels and deadlines differ between Medicare and commercial plans, and tracking them is essential. External review data show that many denials are overturned, so appealing well recovers revenue and, more importantly, supports patients' access to needed care.

References

Centers for Medicare & Medicaid Services. (2025). Original Medicare (fee-for-service) appeals. https://www.cms.gov/medicare/appeals-grievances/fee-for-service

Tseng, P., Kaplan, R. S., Richman, B. D., Shah, M. A., & Schulman, K. A. (2018). Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA, 319(7), 691-697. https://doi.org/10.1001/jama.2017.19148

Wei, L., Zeng, P. P., Kaplan, I., Kong, R., Huang, A., & Winer, A. (2022). Leaving no stone unturned: Factors associated with overturning insurance claim denials for urological conditions in New York State. Urology Practice, 9(6), 568-573. https://doi.org/10.1097/UPJ.0000000000000347