Sample Appeal Letter
This is a worked example of a DenyBack appeal — a Medicare Advantage prior-authorization denial for a lumbar MRI, contested section by section. The notes alongside explain why each part is structured the way it is.
Margaret K.
212 Oakhurst Lane
Naperville, IL 60540
May 18, 2026
Humana Medicare Advantage
Grievances and Appeals Department
P.O. Box 14546
Lexington, KY 40512-4546
RE: Appeal of Prior Authorization Denial
Member ID: H44871290
Denied Service: MRI of the Lumbar Spine (CPT 72148)
Denial Date: April 30, 2026
Dear Appeals Review Board:
I am writing to formally appeal Humana's denial of prior authorization for an MRI of the lumbar spine, denied on April 30, 2026 on the grounds that the imaging is “not medically necessary.” I respectfully request a full reversal of this determination. The denial does not reflect the documented clinical circumstances of my care, and the requested imaging meets the standard of medical necessity under Medicare coverage guidelines and accepted standards of practice.
My treating physician ordered this MRI after more than six weeks of persistent lower back pain radiating into my left leg, accompanied by numbness and weakness that have not responded to conservative treatment. I have completed a full course of physical therapy and a trial of anti-inflammatory medication, both documented in my medical record, without meaningful improvement. Medicare coverage criteria support advanced imaging of the lumbar spine when conservative treatment has failed and neurologic symptoms — such as the radiculopathy I am experiencing — are present. My case meets these criteria directly.
The denial letter states only that the imaging is “not medically necessary,” without addressing the specific clinical findings my physician documented. A blanket determination that does not engage with the presence of radicular symptoms, the failure of conservative care, or the duration of my condition does not constitute an individualized medical necessity review. I request that this appeal be evaluated by a physician with relevant expertise in spinal conditions.
I request a written response to this appeal within the timeframe required of Medicare Advantage organizations. If this appeal is not resolved in my favor, I intend to escalate — with a follow-up to your office, a complaint to my state insurance regulator, and a request for independent external review. I am confident that an impartial review of the clinical record will support the medical necessity of this imaging.
Sincerely,
Margaret K.
Member ID: H44871290
The letter above is step one of four.
DenyBack does not stop at writing the appeal. Here is what happens for Margaret over the next 45 days — whether or not Humana responds.
Day 1
Appeal letter mailed certified to Humana
USPS Certified Mail, return receipt requested.
Day 14
Follow-up letter mailed certified
If Humana has not responded, we escalate.
Day 30
Complaint filed with the Illinois Department of Insurance
State regulator review forces insurer accountability.
Day 45
External review request submitted
Independent physician review — the insurer no longer decides its own case.
All four documents mailed. All certified. All tracked. You do nothing.
This is a sample illustrating DenyBack's appeal structure. We don't share real customer appeals to protect privacy.
Your denial deserves an appeal like this.
DenyBack writes your appeal, mails it certified, and escalates automatically for 45 days. $39 flat. You do nothing.