Level-of-care denials (CO-50, CO-167) are among the most overturned on appeal — especially when you cite the payer's own InterQual or MCG criteria back at them.
TODAY'S DATE
PAYER NAME
Medical Management / Appeals Department
PAYER ADDRESS OR FAX
RE: Appeal of Inpatient Admission Denial — Level of Care
Patient: PATIENT FULL NAME
Date of Birth: MM/DD/YYYY
Member ID: MEMBER ID
Group Number: GROUP NUMBER
Claim Number: CLAIM NUMBER
Admission Date: ADMISSION DATE
Discharge Date: DISCHARGE DATE
Facility: HOSPITAL / FACILITY NAME
Attending Physician: PHYSICIAN NAME, CREDENTIALS
Principal Diagnosis: ICD-10 CODE — DESCRIPTION
Denial Code: CO-50 / CO-167 / OTHER
Denial Date: DATE OF DENIAL NOTICE
Dear Medical Appeals Review Committee,
We are submitting this formal appeal on behalf of FACILITY NAME regarding the denial of inpatient benefits for the above-referenced admission. The denial, received on DATE, states: "QUOTED DENIAL REASON FROM EOB OR DENIAL LETTER."
We respectfully disagree with this determination. The clinical circumstances of this admission supported inpatient-level care under PAYER NAME's own medical necessity criteria and applicable clinical guidelines.
Clinical Summary:
PATIENT NAME presented to FACILITY on ADMISSION DATE with PRESENTING SYMPTOMS / CHIEF COMPLAINT. The admitting diagnosis was DIAGNOSIS (ICD-10: CODE). On presentation, the patient demonstrated the following acute clinical indicators requiring inpatient-level monitoring and intervention:
Medical Necessity Under Payer Criteria:
This admission meets the criteria for inpatient-level care under PAYER NAME's coverage policy POLICY NUMBER / TITLE — search Axlow for exact citation and InterQual [YEAR] / MCG [YEAR] — applicable criteria set, specifically:
The patient's condition could not have been safely managed in an observation or outpatient setting because CLINICAL REASONING — e.g., "the required IV [medication] titration necessitated continuous nursing assessment and physician availability that outpatient or observation status cannot provide".
IF PEER-TO-PEER WAS CONDUCTED: A peer-to-peer review was conducted on [DATE] between Dr. [ATTENDING] and [PAYER REVIEWER NAME/TITLE]. During that review, [brief summary of discussion]. Despite this clinical exchange, the denial was upheld without adequate clinical justification.
Response to Denial Rationale:
The denial states QUOTED DENIAL RATIONALE. This rationale is inconsistent with the documented clinical record for the following reasons:
Supporting Documentation Enclosed:
We request that this denial be reversed and the claim reprocessed for inpatient benefit payment. The total billed amount is $BILLED; the contracted amount due is $CONTRACTED RATE.
If this appeal is denied, please provide a written explanation citing the specific clinical criteria used in the determination, the name and specialty of the reviewing clinician, and instructions for requesting an external independent review. We reserve all rights to pursue further appeal levels including external review and applicable regulatory remedies.
Please respond to this appeal within the timeframe required under applicable state law / ERISA / plan terms.
Respectfully submitted,
SIGNATORY NAME, CREDENTIALS
TITLE — e.g., Director of Revenue Cycle / Case Manager
FACILITY NAME
PHONE | FAX | EMAIL
Search Axlow for your payer's inpatient medical necessity criteria, level-of-care policies, and coverage guidelines — then cite them by name and page in your appeal.