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    Claim Denied? Decode It and Write the Appeal

    2

    Decode an insurance denial letter, gather the evidence that answers it, and write the point-by-point appeal.

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    Claim Denied? Decode It and Write the Appeal

    Claim Denied? Decode It and Write the Appeal

    Example session with this skill installed

    Health insurer denied an MRI of my knee as 'not medically necessary; conservative treatment not documented.' I did 8 weeks of physical therapy and took prescribed anti-inflammatories before my orthopaedist ordered it. Denial letter dated the 3rd, says I have 180 days to appeal internally. Help me appeal.

    • Read your context and instructions
    • Compiled the claim denied decode

    Denial Decode & Appeal: knee MRI — health plan

    1. The decode
    The cited reason is a documentation denial, not a clinical one: the insurer says the file doesn't show conservative treatment before imaging. You did eight weeks of physical therapy and a course of medication, which is exactly the conservative treatment most medical policies require. This is

    answerable: the appeal succeeds by putting the documentation in front of them, not by arguing.

    2. Evidence checklist

    Denial assertionEvidence that answers itWhere to get itStatus
    Conservative treatment not documentedPT attendance record and discharge summary (8 weeks, dates, outcome)Physical therapy clinic☐
    SamePrescription record for the anti-inflammatory coursePharmacy or prescriber☐
    Not medically necessaryOrthopaedist's letter of medical necessity citing persistent symptoms after conservative care and the clinical question the MRI answersOrthopaedist's office☐
    Implicit: policy criteriaThe plan's medical policy for knee MRI (criteria list)Insurer website or by request☐

    3. The appeal letter

    [Your name, member ID, claim number, date]
    Re: Appeal of denial dated [the 3rd], claim [number], MRI right knee, ordered by Dr [name] on [date]

    Your letter of [the 3rd] states: "not medically necessary; conservative treatment not documented." I am appealing this determination and enclosing the documentation.

    1. Conservative treatment was completed and is documented. Enclosure A is the physical therapy record showing eight weeks of treatment from [date] to [date] with persistent symptoms at discharge. Enclosure B is the pharmacy record of the prescribed anti-inflammatory course from [date] to [date].
    2. Medical necessity is established by the treating specialist. Enclosure C is Dr [name]'s letter stating the persistent symptoms after conservative care, the suspected diagnosis, and how the MRI result determines treatment.
    3. Your own criteria are met. Enclosure D is the plan's medical policy for knee MRI, which lists [quote the relevant criterion]. Enclosures A–C satisfy it.

    I request that the denial be overturned and the MRI approved. Please respond within the timeframe required for internal appeals. This letter is sent by [trackable means] on [date].
    [Signature]

    4. Escalation ladder
    Internal appeal (this letter) → second-level internal appeal if the plan offers one → external independent review (your rights section in the denial letter names the route; many plans allow it after internal appeal is exhausted, sometimes concurrently for urgent care) → complaint to the insurance regulator → counsel if the amount justifies it.

    5. Deadlines box
    Internal appeal: 180 days from [the 3rd] →

    [date]. Ask your orthopaedist whether an expedited appeal applies if delay affects treatment. External review window: per the rights section, typically counted from the internal decision. Keep proof of every sending date.

    This is a plain-language reading, not legal/financial advice — laws vary by jurisdiction; confirm anything load-bearing with a qualified professional.

    Connects securely to your tools. The creator never sees your data.

    What you get

    The denial reason decoded with honest appeal odds.An evidence checklist matched to the denial type.The full appeal letter, point by point, enclosures referenced.The escalation ladder and every deadline in one box.

    About this skill

    The problem

    Denial letters cite reasons like 'not medically necessary' or 'pre-existing condition' that sound final and often aren't. Most people never appeal, and the ones who do send a story instead of a point-by-point rebuttal with documents.

    What it does

    • Decodes the cited reason into plain English, its type, and an honest read of appeal odds.
    • Builds an evidence checklist matched to the denial type, with where to get each item.
    • Writes the full appeal letter: quoted denial, point-by-point response, policy language, enclosures, the specific request.
    • Maps the escalation ladder: internal appeal levels, external review, regulator complaint.
    • Puts every deadline from the letter and the policy in one box.

    Why this beats prompting it yourself

    A general prompt writes a letter that says you disagree. This skill quotes the denial back, answers each assertion with a referenced enclosure, cites the policy's own wording, and respects the appeal clock.

    Use cases

    • A health insurer denied a procedure as not medically necessary.
    • A home claim was denied citing wear and tear.
    • An auto claim was reduced citing a policy exclusion.
    • You have 30 days left on an appeal deadline.

    Known limitations

    Not legal advice. Appeal rights, external review, and deadlines are jurisdiction- and plan-dependent; the skill tells you to check the denial letter's own rights section. Without a written denial, the first move is to request one.

    How to install

    Works the same in every agent - Claude, Cursor, Codex, Copilot and 20+ more.

    ~30 seconds
    1. 1

      Download the ZIP

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    2. 2

      Unzip into your skills folder

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    3. 3

      Ask your agent to use it

      Restart the agent if it was already running. It picks the skill up automatically - no config needed.

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