Experimental / Investigational Appeal Letter

Use this when the payer's medical policy classifies the service as experimental for this indication. It's the hardest to win and the highest-dollar — it lives or dies on the evidence you attach and, often, a peer-to-peer with the medical director.

What makes it win

• Attach peer-reviewed literature and specialty-society clinical guidelines supporting the service for this specific indication
• Cite FDA status (approval/clearance) and any part of the payer's own policy that does cover it
• Document why standard, covered alternatives were inappropriate or exhausted for this patient
• Request a peer-to-peer or medical-director review so the evidence is read by a clinician

The template

Replace the [BRACKETED] fields with your details. This is the manual version of the appeal Volari files for you automatically.

[PRACTICE LETTERHEAD]
[DATE]

[PAYER NAME] — Appeals Department / Medical Director
[PAYER APPEALS ADDRESS]

RE: Appeal of Experimental/Investigational Denial (CARC 55)
Patient: [PATIENT NAME]   Member ID: [MEMBER ID]
Claim #: [CLAIM NUMBER]   Date of Service: [DOS]
CPT/HCPCS: [CPT CODE]   Diagnosis: [ICD-10 CODE]

To the Medical Director / Appeals Department:

We are appealing the denial of [CPT CODE / SERVICE] as experimental or investigational. For this patient's indication, the service is supported by published evidence and established clinical use, and we request review of the enclosed literature.

[PATIENT NAME] has [DIAGNOSIS / CLINICAL HISTORY]. Covered alternatives were [tried and failed / contraindicated]: [SPECIFICS WITH DATES]. The enclosed evidence supports this service for this indication: [CITE 1-3 PEER-REVIEWED STUDIES / SPECIALTY-SOCIETY GUIDELINE]. The service is [FDA-approved / FDA-cleared] for [INDICATION], and [PAYER]'s policy [POLICY NUMBER] covers it when [CRITERION], which this patient meets.

Given the clinical stakes, we request a peer-to-peer review with the treating provider, [PROVIDER NAME], reachable at [PHONE].

Enclosed: office note dated [DOS], [cited literature], [FDA reference].

Sincerely,
[PROVIDER NAME], [TITLE]
[PRACTICE NAME] — NPI [NPI]   TIN [TIN]

Common questions

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