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Text Box: Model Letter of Appeal Date (Name of claims administrator) (Name/address of UR Company) RE: (name of injured worker) (date of injury) (claim number) (name of employer) (occupation of injured worker) Dear (name of claims administrator): I am in receipt of a letter dated (insert date) from (name of UR company) which is (denying, modifying, delaying – insert whatever is appropriate) my medical treatment request for the following services: (list requested services). The utilization reviewer, (insert name of reviewer if known) has (denied, modified, or delayed – select whatever is appropriate) based on: (list rationale given by the physician reviewer). I disagree with this decision for the following reasons: (list your rationale as to why your medical treatment requested is medically indicated and any potential harm to the injured worker by delaying treatment. In this section, specifically list why the reviewer is incorrect in their conclusions. Include portions of the injured worker’s medical history to support your treatment request. If the reviewer quotes: 1) the ACOEM Practice Guidelines incorrectly or out-of-context, list the citation and why the citation is inappropriate; 2) list other sections of ACOEM that support the need for the medical treatment; 3) cite other evidence-based nationally recognized practice treatment guidelines and/or published articles that support the need for the treatment; and, 4) list any co-morbidities that might clarify the need for surgery and/or additional treatment/diagnosis. Be as specific as possible listing the specific citation including page numbers.) I hereby continue to request authorization for the following medical services: (list medical treatment requested.) If this appeal does not resolve this dispute, I hereby request that the dispute be resolved in a timely manner as provided for under Labor Code Section 4062. If approval of these medical services is not received prior to (30 days), I will have no choice but to issue a Permanent and Stationary report on this injured worker as I will not be able to cure or relieve this injury without approval of the requested medical treatment. Respectfully submitted: (Name of Treating Physician)