Hardship Letter Examples

   Mammogram Denial Appeal

{Phone #}


Dear {insurance company representative}:

I am writing to appeal the charge of {amount} for my mammogram performed at {facility} on {date}. The bill reference number is {number}.

This facility, which is a preferred provider under my plan, performs 3D mammography exclusively. However, your company contends that its policy is to only cover 3D mammograms for diagnostic, not screening, purposes, calling the procedure "experimental and investigational." Because the facility does not offer the old two-dimensional x-ray style of mammogram, I had no option for my screening mammogram other than 3D. Additionally, my doctor has advised 3D mammography as the best option for me due to dense breast tissue.

I am not in a financial position to pay the amount billed. Due to {situation}, it would create an extreme hardship for me and my family.

Moreover, facility staff has advised me that filing an appeal will help in its ongoing efforts to best serve patients by offering the most-advanced standard of care. Research shows that 3D mammography does a better job of detecting small-yet-invasive cancers and also results in fewer false positives (read: expensive callbacks). Digital Breast Tomosynthesis was approved by the FDA many years ago, and the Centers for Medicare and Medicaid Services has been covering 3D mammograms as part of preventative screening since 2014.

I urge you to reverse your decision and cover my 3D mammogram in full.


{Sender Name}

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