Sample Insurance Appeal Letters

​This letter is my formal appeal of the rejection of Claim Number _____ for Lactation Consultation Services provided to my son, (Name) on (Date) for the amount of _____.

Summary of Events: Child was born on (Date). He was discharged from the hospital on (Date) (Detail here whatever complications you had with feeding/jaundice/dehydration/re-admittance to hospital, etc) On (Date) we met with our pediatrician, (Name) and expressed concerns about breastfeeding. Dr. _______ noted that baby was struggling to thrive and referred us to Lactation Consultant, Deborah Dominici RN, IBCLC, RLC. Deborah provided her services on (Date). Following the consultation, I submitted all required paperwork to (name of insurance company) for reimbursement. On (Date), I received an Explanation of Benefits (referenced above), noting the claim was denied.

Call to Customer Support: On (date) I called the Insurance Company customer service line with questions regarding the Explanation of Benefits dated (Date). The CSR stated that Lactation Consultations are covered by our plan under two scenarios; (a) when under hospitalization following birth or (b) if the infant is “Struggling to Thrive” and that (baby’s name) had not met either of these criteria. Additionally, the CSR also explained that even if he was eligible for the benefit, the Lactation Consultant we used is not an “In Network” provided. I informed the CSR that it is not possible to identify an “In Network” Lactation Consultant using the Insurance Company online search tool. She reviewed the tool and confirmed.

Basis of Appeal: Based on (Baby’s name) medical history and our pediatrician’s observation, (Baby’s name) was “Struggling to Thrive,” which means we met the criteria for coverage under our plan. Additionally, the question of “In Network” vs. “Out of Network” is irrelevant since it’s not actually possible to locate an “In Network” Lactation Consultant using the (Insurance Company) system. Because we could not locate a provider using the (Insurance Company) system, we used Deborah Dominici, the Lactation Consultant recommended by our Pediatrician. Deborah is certified by the International Board of Lactation Consultant Examiners (IBLCE), which is the recognized association in the field. If a service is covered by our plan, it’s only fair that we can have it preformed. In this case, (name of insurance company) has made that unreasonably burdensome to locate a provider, so one was selected based on the Pediatrician’s recommendation.

Additional Information: The American Academy of Pediatrics recommends that all babies be breastfed for at least one year. Additionally, the AAP recommends mothers and babies be seen by a board certified lactation consultant when breastfeeding difficulties occur. The AAP also recommends that third party insurance reimbursements be made for lactation help.




DATE
To Whom This May Concern:
This letter is my formal appeal of the rejection of Claim Number CLAIM NUMBER for Lactation Consultation Services provided to my child, NAME on DATE for the amount of $$ .
Summary of Events: My child was born on DATE . Baby was discharged from the hospital on DATE . (Detail here whatever complications you or your baby had with pain/tissue trauma/ feeding/ jaundice/ dehydration/ re-admittance to hospital, etc) . On DATE we met with our provider, NAME , and expressed concerns about breastfeeding. Dr. NAME noted that baby was struggling to thrive and referred us to our Lactation Consultant, Deborah Dominici RN, IBCLC, RLC. Deborah provided her services on DATE . Following the consultation, I submitted all required paperwork to name of insurance company for reimbursement. On DATE , I received an Explanation of Benefits (referenced above), noting the claim was denied.
Call to Customer Support: On DATE , I called INSURANCE COMPANY NAME customer service line with questions regarding the Explanation of Benefits dated DATE . The CSR stated that Lactation Consultations are covered by our plan under two scenarios; (a) when under hospitalization following birth or (b) if the infant is “Struggling to Thrive” and that BABY’S NAME had not met either of these criteria. Additionally, the CSR also explained that even if our baby was eligible for the benefit, the Lactation Consultant we used is not an “In Network” provided. I informed the CSR that it is not possible to identify an “In Network” Lactation Consultant using the Insurance Company online search tool. The CSR reviewed the tool and confirmed.
Basis of Appeal: Based on BABY’S NAME medical history and baby’s provider’s observation, BABY’S NAME was “Struggling to Thrive,” which means we met the criteria for coverage under our plan. Additionally, the question of “In Network” vs. “Out of Network” is irrelevant since it’s not actually possible to locate an “In Network” Lactation Consultant using the INSURANCE COMPANY NAME system. Because we could not locate an IBCLC using the INSURANCE COMPANY NAME system, we used Deborah Dominici, the Board Certified Lactation Consultant recommended by our provider. Deborah is a registered nurse and certified by the International Board of Lactation Consultant Examiners (IBLCE), which is the recognized association in the field. If a service is covered by our plan, it’s only fair that we can have it preformed. In this case, INSURANCE COMPANY NAME has made that unreasonably burdensome to locate a provider, so one was selected based on our provider’s recommendation.
Additional Information: The American Academy of Pediatrics recommends that all babies be breastfed for at least one year, longer than one year if possible. Additionally, the AAP recommends mothers and babies be seen by a board certified lactation consultant when breastfeeding difficulties occur. The AAP also recommends that third party insurance reimbursements be made for lactation help.
I ask you to reconsider and approve payment for this claim.
Sincerely,




Thank you to the parents who provided this sample letter so that other parents may be reimbursed for lactation services. All of my clients receive an insurance claim form and are encouraged to file a claim with their insurance company. There also is an option for my insurance specialist to file a claim for them. Many insurance companies are now covering my consultations. If a claim is denied, appeals are often successful. In the state of Hawaii, you may also file a complaint with the insurance commissioner, For more information, contact Deborah Dominici, RN, IBCLC, RLC