Part 2: From Evidence to Action —
Drafting a Data-Driven Appeal That Gets Results
In Part 1, we decoded the denials and gathered your supporting evidence. Now it’s time to put it all into motion — drafting a clear, data-driven appeal that makes reviewers sit up and take notice.
Step 1: Structure Your Appeal Like a Legal Brief
Start your letter with:
Patient Name | DOB | Member ID | Claim (ICN)
Then go straight to the point — identify the denied CPT® code and cite the payer’s policy and your supporting documentation.
Example:
CPT® [XXXXX] was incorrectly denied as “not medically necessary” (CO50). According to [Payer Name] Policy #[###], this service meets medical necessity criteria for [diagnosis], supported by [findings].
Step 2: Annotate Your Medical Record
Your medical record is your star witness.
- Underline key findings (never highlight — it may not scan).
- Add text boxes and arrows with short notes:
“Physician’s findings supporting CPT® [XXXXX] are documented here.”
This directs the reviewer’s eyes exactly where you need them to look.
Step 3: Submit Securely & Follow Up
Submit appeals through the payer’s secure online portal to get instant tracking confirmation. Summarize your argument clearly and request reconsideration — along with an explanation of how policy was applied.
Calendar a two-week follow-up to ensure your appeal doesn’t vanish into limbo. If results are unsatisfactory, escalate with confidence.
Closing the Case
Every overturned denial strengthens your revenue cycle — and your team’s expertise.
If your practice is ready to reduce denials and recover lost revenue, contact Sunrise Services today. Our team helps independent practices and rural clinics streamline billing, strengthen documentation, and get reimbursed faster.
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