Use this template as a starting point. Replace each bracketed field with your own information and follow your plan's instructions for submitting an appeal.
[Your Name] [Your Address] [City, State ZIP] [Date]
[Insurance Company Name] Attn: Appeals Department [Insurer Address]
RE: Formal Appeal of Denial for Applied Behavior Analysis (ABA) Therapy Services Member Name: [Child's Full Name] Member ID: [Insurance ID Number] Date of Denial: [Date of Denial Letter] Claim/Reference Number: [Claim Number]
Dear Appeals Department,
I am writing to formally appeal your decision to deny coverage for Applied Behavior Analysis (ABA) therapy services for my child, [Child's Name], who was diagnosed with Autism Spectrum Disorder (ASD) on [Diagnosis Date] by [Diagnosing Provider's Name, Credentials].
[If applicable, name your state's autism insurance mandate here, for example: "Under [State] law ([Statute name/number]), health plans issued in this state are required to cover the diagnosis and treatment of autism spectrum disorder, including ABA therapy, when prescribed as medically necessary."]
ABA therapy has been recommended by [Prescribing Physician/BCBA Name, Credentials] based on [brief clinical rationale, for example: "a comprehensive diagnostic evaluation and functional behavior assessment"].
I am requesting that you:
- Reverse the denial and approve coverage for ABA therapy services as prescribed.
- Provide a written explanation of the specific medical necessity criteria used in this determination, if you decline this appeal.
- Explain any available next-level or external review options if this appeal is denied.
Enclosed with this letter
Please respond within the timeframe required under my plan's policy or applicable state law. If you need any additional information to process this appeal, please contact me at [phone number] or [email address].
Thank you for your prompt attention to this matter.
Sincerely, [Your Name] Enclosures: [list] cc: [Child's pediatrician / BCBA, if applicable]
- A copy of the denial letter
- [Diagnosing provider]'s diagnostic evaluation and treatment recommendation
- [BCBA/prescribing provider]'s letter of medical necessity
- [Any other supporting documentation, e.g., prior treatment records]
