Prompt details

Tested on

Claude Opus 5.5

Length

578 words · 3 fill-ins

Example input

[Denial letter]: Brightline Health Plan Notice of Adverse Benefit Determination Member ID ending 2204. Plan: Brightline Choice PPO (group plan through my employer). Date of notice: Day 1. Request: MRI lumbar spine without contrast (CPT 72148), requested by my spine doctor at Piedmont Spine & Orthopedics as a prior authorization. Decision: Denied. Reason: Not medically necessary. Our clinical criteria for advanced imaging of the lumbar spine require documentation of at least 6 weeks of conservative treatment, such as physical therapy, medication and activity changes, unless red-flag symptoms are present. The records we received did not show 6 weeks of conservative treatment or red-flag symptoms. Clinical criteria used: Brightline Advanced Imaging Guideline AI-LS-04. Your right to appeal: You or your provider may request an internal appeal within 180 days of the date you receive this notice. Send your appeal in writing to Brightline Appeals at the address on page 2, or by fax. If your situation is urgent, you or your doctor may ask for an expedited appeal by phone. You may request, free of charge, copies of all documents and the clinical criteria used in this decision. Your provider may ask for a peer-to-peer review within 14 days of this notice.

[Policy wording]: From my plan's Evidence of Coverage: Section 4.2 Prior Authorization: "Certain services, including advanced imaging (MRI, CT and PET), require prior authorization. Services that require prior authorization and are performed without it, or that are denied, are not covered." Section 1 Definitions, Medically Necessary: "Health care services that a provider, using prudent clinical judgment, would provide to a patient to diagnose or treat an illness, injury or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient or provider." Section 9.1 Appeals: "A member may submit written comments, documents, records and other information relating to the claim. The review will take into account all information submitted, without regard to whether it was submitted or considered in the initial determination."

[Your records and timeline]: - About 10 weeks ago: lower back pain started after lifting boxes at work. The pain runs down my left leg to the foot. - 9 weeks ago: primary care visit. Prescribed naproxen and told to stay active. The note says "left L5 radicular pain". - 8 weeks ago to 2 weeks ago: 12 physical therapy sessions over 6 weeks at Carolina Motion PT, twice a week. I have the PT discharge summary: "minimal improvement, recommend imaging and specialist follow-up". - 4 weeks ago: numbness on the top of my left foot started. It is still there. - 3 weeks ago: Piedmont Spine visit. The spine doctor's note says "persistent L5 radiculopathy despite 6 weeks of PT and NSAIDs, new sensory deficit dorsum of left foot, MRI to evaluate for disc herniation and plan possible injection." - Day 1: denial notice. I think the spine office sent only their own visit note, not the PT records or the primary care note. - I live in North Carolina. I don't know if my employer's plan is self-funded. I have not appealed yet. Today is Day 12.

Example output

1. The denial in plain English

Brightline denied prior authorization for your lumbar MRI (CPT 72148) as "not medically necessary." Their guideline AI-LS-04 requires at least 6 weeks of conservative treatment, unless red-flag symptoms are present, and the records they received showed neither. Your records appear to show the conservative treatment: naproxen from 9 weeks ago and 12 PT sessions over 6 weeks. It looks like those records were never sent, so this denial is mainly a missing-documents problem, and Section 9.1 requires the appeal to consider new records. Urgent: a peer-to-peer review must be requested "within 14 days of this notice," and today is Day 12, so call your spine doctor's office today.

*Assumptions:* "Day 1" is when you received the notice. Whether your plan is self-funded is unknown, so I give both routes in Part 6.

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2. Policy language

Clause (quoted)	What it requires	What my records show	Met or Gap
§4.2: "Certain services, including advanced imaging (MRI, CT and PET), require prior authorization."	Approval before the MRI	Piedmont Spine requested prior authorization	Met
§4.2: "Services that require prior authorization and are performed without it, or that are denied, are not covered."	A denied MRI is not paid	Denied on Day 1	Gap. Don't schedule the MRI until it is approved, or you may owe the full cost.
§1: "Health care services that a provider, using prudent clinical judgment, would provide to a patient to diagnose or treat an illness, injury or its symptoms"	A provider's clinical judgment that the service is needed to diagnose or treat	Spine note: "MRI to evaluate for disc herniation and plan possible injection." PT discharge: "recommend imaging and specialist follow-up."	Met on your records. The PT summary is not yet in the file.
§1(a): "in accordance with generally accepted standards of medical practice"	Consistent with accepted practice	No document addresses this yet	Gap: [ask your doctor] to address it in a letter of medical necessity
§1(b): "clinically appropriate in type, frequency, extent, site and duration"	Right test, right timing	One MRI, lumbar, without contrast, after PT and NSAIDs	Partly met. Your doctor should explain why this test, and why now.

Claude Opus 5.5

Appeal a Denied Insurance Claim – Insurance appeal letter prompt for ChatGPT and Claude

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Claude Opus 5.5

This prompt writes an appeal for a denied health, home or auto insurance claim. Paste the denial, the policy wording and your records; you get the reason in plain English, an evidence checklist, the letter and your deadlines.

What you get

The denial reason in plain English, and what would change it
Your policy's own words matched to your records, clause by clause
An evidence checklist and the appeal letter, ready to send
A medical necessity outline for your doctor, and every deadline and next level

How to use it

1
Gather the denial and the policy
Get the full denial letter and the plan document, and request the criteria the insurer used, as the denial letter explains.
2
Read the policy table
Every row marked Gap is a document to get before you send the appeal.
3
Send before the deadline and track it
Send the appeal with copies of the evidence, keep proof of the date it arrived, and note the decision date and the next level.

Better results

Ask your doctor's office whether it already appeals denials or can request a peer-to-peer review, and hand over the medical necessity outline.
If the clause you need is not in what you pasted, ask the insurer for the full plan document and run the prompt again with it.
Follow up with: "Which sentence in my appeal would a reviewer find weakest, and which record would fix it?"

Questions

Can ChatGPT write an insurance appeal letter?

Yes. ChatGPT, Claude or Gemini can write a strong insurance appeal letter when you paste the denial letter, the policy wording and your records. It should answer the insurer's exact reason with evidence and quote only your policy. No letter guarantees the denial is overturned.

How long do I have to appeal a health insurance denial?

For most US health plans, you have 180 days from the denial notice to file an internal appeal, and 4 months after a final denial to ask for an external review. Check the deadline printed in your denial letter, since your plan's own terms come first.

What is an external review?

An external review is a check of your denied health claim by an independent reviewer after the insurer's own appeal fails. Your insurer is required to accept the reviewer's decision. For most plans, you ask for it within 4 months of the final denial.

Should my doctor write the appeal?

Your doctor's letter of medical necessity is often the strongest evidence in a health appeal, and many offices handle prior authorization appeals themselves. This prompt gives you an outline of what that letter should cover, built from your own records, to hand to the office.

Updated 8 Nov 2026