For insured patients · Appeals department calls
You have the denial letter. Rehearse what happens when they say “not medically necessary.”
The EOB says denied. Your doctor says the MRI is warranted. You still don’t know what you’ll say when appeals cites plan exclusions and tells you to file in writing.
The claim denial arrived: $4,800 for an MRI your neurologist ordered after six weeks of symptoms. Your doctor’s office said they’ll write a letter of medical necessity. You’re supposed to call the appeals number on the EOB before you submit anything — to pin down the exact criterion they used and what documentation reverses it. What you can’t picture is the rep saying “CO-50, not medically necessary per plan guidelines” and deflecting every follow-up with “you’ll need to submit a formal written appeal.” Kommi puts you in that call first — with an appeals representative who pushes back the way real insurer phone lines do — so your first real conversation isn’t your first take.
The denial letter isn’t the hard part.
Every insurance-appeal guide has the same playbook: call the appeals department (not member services), ask for the specific denial criterion, get the rep’s name and a call reference number, request peer-to-peer review if needed. You have the claim number highlighted. What you don’t have is muscle memory for when the rep says “I can’t discuss clinical criteria over the phone” and you have to decide in real time whether to push harder, ask for a supervisor, or hang up without the answers you need for your written appeal.
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What’s at stake
Accepting a $4,800 MRI denial when your doctor documents medical necessity costs you the scan out of pocket — or delays treatment while you re-file. One vague call can leave you without the specific plan guideline to rebut in writing.
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Why you procrastinate
You dread hold music, scripted deflections, and reps who rush you off the line. You keep rereading the EOB but skip the part where appeals says “submit in writing” before you’ve pinned down what they actually need.
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What templates can’t do
Appeal-letter templates give you paragraphs for the written filing. They can’t simulate the rep citing CO-50, refusing to quote the plan guideline, then pivoting to “your provider can request peer-to-peer” before you finish your questions.
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What advocates cost
Patient advocates charge $150–$400/hr or a cut of what they recover. You need to know whether you can hold the appeals line credibly yourself before you hand over a third of a reversed claim.
Sample roleplay · 3 minutes
“The claim was denied as not medically necessary. You’ll need to submit a written appeal.”
You’re Casey. You have the EOB. Now you’re on the phone with the insurer’s appeals department.
You (Casey)
“Hi, my name is Casey Morgan, member ID A4829103. I’m calling about claim number CLM-2026-884729 denied on March 8 for an MRI of the lumbar spine on February 14. The letter says CO-50, not medically necessary. I need the specific plan guideline or clinical criterion used to deny this, and what documentation would reverse the decision on appeal.”
Appeals representative
“I see the claim here. The denial is based on our medical policy — the service wasn’t deemed medically necessary for your diagnosis. I can’t discuss clinical criteria over the phone. You’ll need to submit a formal written appeal with supporting documentation from your provider. Would you like me to mail you an appeal form?”
Your move
- → Insist on the specific policy name or denial criterion before ending the call — you need it for your written rebuttal
- → Ask whether peer-to-peer review is available and request the appeals filing deadline in writing
- → Get the rep’s name, today’s date, and a call reference number before you hang up
Each choice changes how appeals responds. The conversation gets bureaucratic and evasive. You practice pinning down the denial criterion without sounding hostile — or catching yourself when you’re about to accept “just file in writing” without the answers your doctor needs to draft the letter of medical necessity.
Then the coach reads you back to yourself.
Not an appeal-letter template. Not a list of CARC codes. One observation about what you did, one adjustment for next time, one sentence you can carry into the appeals call.
Sample coach debrief
“You opened with member ID, claim number, and the CO-50 denial code — strong, specific start. When appeals said they couldn’t discuss clinical criteria, you said ‘okay, can you mail the appeal form?’ before asking for the policy name or a supervisor. That let them close the call without giving you the criterion your written appeal needs to rebut.
Try next time: Pause after the deflection. Say: ‘I understand I need to file in writing. Before we end the call, can you confirm the specific medical policy or plan guideline cited for this denial, and whether peer-to-peer review is available? I also need your name and a call reference number for my records.’
Carry into the call: “I’m not disputing that I need to appeal in writing — I’m asking for the specific criterion your reviewer used so my doctor’s letter of medical necessity addresses it directly. What is the policy name, and what documentation would overturn denial CLM-2026-884729?””
Questions before you call appeals
- Isn’t the written appeal what actually overturns a denial?
- Yes — but the phone call is how you learn what to put in that letter. Patient advocates and state CAP guides both say: call appeals first to pin down the exact criterion, required documentation, and deadline. Kommi rehearses that call so you don’t hang up with a form and no answers.
- I already have appeal-letter templates. Why practice the call?
- Templates tell you what to write after you know the denial criterion. They don’t prepare you for appeals deflecting to “submit in writing,” refusing to name the plan guideline, or rushing you off before you get a reference number. Kommi is where you hear yourself fold under scripted pressure — and fix it before it weakens your appeal.
- What if they say they can’t discuss clinical criteria?
- That’s one of the most common paths in the roleplay. You practice asking for the policy name, peer-to-peer availability, filing deadline, and call reference number — without accepting a vague answer that leaves your doctor guessing what to address in the letter of medical necessity.
- How is this different from negotiating a hospital bill?
- Hospital billing negotiates chargemaster rates and payment plans with the facility. Insurance appeals are about coverage your plan already owes — citing medical necessity, plan guidelines, and peer-to-peer review with your insurer. Different rep, different script, different stakes. Kommi has pages for both.
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