Appeal of Denied Dental Claim,
With Additional Information

Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

Date

re:  claim # 123456789
John Doe, 4184369178887

This is an APPEAL of claim 123456789. Please re-review this claim, with consideration to the following additional information.

Patient has an existing fixed bridge 18-X-20 replacing missing 19, which was done in May 1998.  Tooth 18 now has recurrent distal caries under the retainer crown. 

Patient is missing 1, 2, 14, 16, 17, 19, 30, 31, 32.

Rather than allowing a new fixed bridge, you are allowing alternative benefit of a removable partial denture. This still does not address the original problem, however, which is recurrent caries on #18.  This is a failure of the bridge, necessitating its removal and replacement. Even with a removable partial denture, new crowns would still be needed on 18 and 20.

Respectfully,

 

Dr. _____