This is the letter ClaimKicker generates. No lawyer-speak. Every quote is verbatim from the patient's record.
Synthetic case — Sarah Chen, an imaginary patient whose Aetna knee-MRI claim was denied for "not medically necessary." The letter below is what would go to Aetna for a real case with similar evidence.
Sarah Chen DOB: 1991-08-15 Aetna Member ID: W123456789 Claim Number: AETNA-2026-0315-7782 Date of Service: March 15, 2026
April 12, 2026
Aetna Appeals Department PO Box 14463 Lexington, KY 40512 VIA FAX: 1-877-852-4929
RE: Formal Appeal — Denial of Claim AETNA-2026-0315-7782
Authority: ERISA §503 (29 U.S.C. §1133) and 29 CFR §2560.503-1
To the Appeals Committee:
I am filing this formal internal appeal of the above-referenced claim denial. The denial, dated April 5, 2026, states the claim was rejected as "Not medically necessary (Reason Code N115). Aetna Clinical Policy Bulletin #0171 requires documentation of at least 6 weeks of failed conservative management prior to imaging." and cites Aetna Clinical Policy Bulletin #0171 as the governing policy.
The denial is inconsistent with Aetna's own published medical policy. My medical record demonstrates that every criterion in CPB #0171, Section II.B has been fully satisfied. Below, I map each policy requirement to the documented evidence in my medical record.
Aetna CPB #0171, Section II.B requires:
(1) Conservative treatment has failed for a minimum of 6 weeks, documented by: Trial of NSAIDs or similar anti-inflammatory regimen, AND Physical therapy or home exercise program
(2) Physical examination findings consistent with internal derangement, including one or more of: Joint line tenderness, Positive McMurray, Apley, or Thessaly test, Joint effusion, Locking or mechanical symptoms
Evidence that these criteria are met:
| Policy Requirement | Documentation in Record |
|---|---|
| NSAID trial | "Ibuprofen 800mg TID × 3 weeks — inadequate relief" (Dr. Ortho, 3/15/2026) |
| Physical therapy | "Physical therapy (6 sessions, 11/2025 - 12/2025) at Bay Area Sports PT, Dr. Karen Reyes, DPT — focused on quad/hamstring strengthening. Patient compliant. No significant improvement." (Dr. Ortho, 3/15/2026) |
| Additional conservative tx | "Cortisone injection (intra-articular right knee, 01/15/2026) — 3 weeks of partial relief, then return of symptoms" (Dr. Ortho, 3/15/2026) |
| Total duration | 6+ months of documented conservative management (September 2025 – March 2026) |
| Joint line tenderness | "Joint line tenderness, medial" (Dr. Ortho, 3/15/2026 physical exam) |
| Positive McMurray | "Positive McMurray sign" (Dr. Ortho, 3/15/2026 physical exam) |
| Joint effusion | "Right knee: moderate effusion (grade 2)" (Dr. Ortho, 3/15/2026 physical exam) |
Every requirement of CPB #0171 Section II.B is satisfied, documented, and exceeds the minimum threshold.
Requested Action:
I respectfully request that Aetna reverse this denial and issue payment for the MRI performed on March 15, 2026.
Per 29 CFR §2560.503-1(i), Aetna must issue a decision on this appeal within 60 days of receipt of this letter. If Aetna does not reverse the denial, I will proceed to external review under ACA §2719 (42 U.S.C. §300gg-19) and, if necessary, file a consumer complaint with the California Department of Managed Health Care.
I have also authorized ClaimKicker (an administrative-services company acting as my authorized representative under 29 CFR §2560.503-1(b)(4)) to assist with communications regarding this appeal. All correspondence may be directed to me at the email and phone below, or to ClaimKicker at support@claimkicker.com.
Respectfully,
_________________________________________ Sarah Chen DOB: 1991-08-15 Member ID: W123456789 Email: sarah.chen@example.com Phone: (415) 555-0123
Attachments:
- Denial letter dated April 5, 2026
- Dr. Robert L. Ortho, MD medical record (office visit, 3/15/2026)
- Bay Area Sports PT discharge summary (12/15/2025)
- Imaging records (X-ray right knee, 2/20/2026)
Before the letter is drafted, the matcher maps each criterion from the insurer's own policy to the verbatim sentence in the doctor's note that proves it was met.
| Policy requirement | Evidence in record | Met? |
|---|---|---|
| Conservative treatment has failed for a minimum of 6 weeks, documented by: Trial of NSAIDs or similar anti-inflammatory regimen, AND Physical therapy or home exercise program | doctor_notes“Ibuprofen 800mg TID × 3 weeks — inadequate relief” doctor_notes“Physical therapy (6 sessions, 11/2025 - 12/2025) at Bay Area Sports PT, Dr. Karen Reyes, DPT — focused on quad/hamstring strengthening. Patient compliant. No significant improvement.” doctor_notes“Cortisone injection (intra-articular right knee, 01/15/2026) — 3 weeks of partial relief, then return of symptoms” | yes |
| Physical examination findings consistent with internal derangement, including one or more of: Joint line tenderness, Positive McMurray, Apley, or Thessaly test, Joint effusion, Locking or mechanical symptoms | doctor_notes“Right knee: moderate effusion (grade 2)” doctor_notes“Joint line tenderness, medial” doctor_notes“Positive McMurray sign” | yes |