A redacted, fully-cited appeal letter — what Denvow produces.

Every appeal letter on Denvow is built from the same Texas-state / ERISA / ACA framework that this sample letter demonstrates. The content is redacted across the board, but the citation pattern, the appeal-rights language, and the procedural timing are all drawn from the live model behind your draft. Read it once, then draft yours in under 2 minutes.

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01 · The worked sample

A letter with three citation channels — state statute, ERISA procedure, and ACA appeal rights.

The letter on the left shows a redacted first-stage appeal of a continuous-glucose-monitor (CGM) supplies denial. The plan’s determination letter omitted the clinical-criteria disclosure and the internal-appeal pathway required under 45 C.F.R. § 147.136(b)(3), framed the denial on a step-therapy rationale that does not survive the Nondiscrimination obligation, and failed to identify the medical or vocational experts whose advice the plan relied on, as 29 C.F.R. § 2560.503-1(j)(4) requires.

The appeal response below cites three federal frameworks at once — the ACA Nondiscrimination rule, the ERISA claims-procedure regulation, and the controlling Texas Insurance Code sections on adverse determination — and reserves the four-month external-review window under 45 C.F.R. § 147.136(d) and the claims-file right under 29 C.F.R. § 2560.503-1(m). Each citation block is paired with an explainer card on the right.

Formal internal appeal — denial of continuous-glucose-monitor suppliesvia Denvow

August 13, 2026

Attention: Internal Appeals and External Review Coordinator

Horizon Compass PPO — Member Appeals Unit, 1428 Peachtree Street NE, Atlanta, GA 30309

Sent by: Priya R. Banerjee

Address: 218 S. Salina Street, Apt. 4B, Syracuse, NY 13202 · Member ID ending 7294 · Claim HC-9001-448

Re: First-stage internal appeal of July 30, 2026 denial — claim HC-9001-448 — continuous-glucose-monitor (CGM) supplies

Plan sponsor: ACME Regional Group Health Plan

I am writing to formally appeal the July 30, 2026 denial of the above claim — the denial of continuous-glucose-monitor (CGM) supplies that my treating endocrinologist, Dr. M. Castellanos, prescribed on clinical-medical-necessity grounds following an in-person evaluation of June 4, 2026. The plan’s letter of July 30, 2026 cites reason code “step-therapy exception denied” yet does not identify which preferred formulary alternative the plan proposes, does not describe the plan’s internal appeals pathway, and does not disclose the four-month external-review window that applies to this determination. Please treat the gaps in the determination letter as a matter of regulatory non-conformance and process this appeal as a first-stage internal appeal under the controlling federal framework below.

45 C.F.R. § 147.136

ACA appeal-rights language

Under 45 C.F.R. § 147.136(b)(2) — the ACA marketplace internal-appeal rule — an issuer must provide a meaningful internal-appeal procedure for adverse benefit determinations on plan benefits, and under 45 C.F.R. § 147.136(b)(3)(i) — the disclosure rule — the determination letter must include a description of the internal-appeal procedure, the right to external review under (d), and the four-month window in which that right may be exercised. The letter of July 30, 2026 omits all three disclosures. I therefore reserve my right to external review and ask that the plan issue a corrected determination letter under the same regulation.

Cited: 45 C.F.R. § 147.136(b)(2)–(3), (d)

ACA marketplace plans are bound by 45 C.F.R. § 147.136 — internal appeal under (b)(2), the four-month external-review window under (d), and expedited review for ongoing treatment under (b)(3). The letter reserves the right to external review and frames the Nondiscrimination standard on the formulary-step or clinical-criteria question.

ERISA § 1133

ERISA procedural timing

Should this plan be administered on a self-funded basis (Plan sponsor: ACME Regional Group Health Plan), the appeal is also timely under 29 C.F.R. § 2560.503-1(h), which implements ERISA § 503 (29 U.S.C. § 1133). The plan’s denial letter of July 30, 2026 does not identify the medical or vocational experts whose advice formed the basis of the denial, as required by § 2560.503-1(j)(4), and a complete claims file is requested under § 2560.503-1(m). The plan is asked to issue a full and fair review under ERISA § 503 and to confirm receipt of this appeal within five (5) business days.

Cited: 29 C.F.R. § 2560.503-1(h), (j)(4), (m); 29 U.S.C. § 1133

Self-funded ERISA plans are governed by the Department of Labor claims-procedure regulation at 29 C.F.R. § 2560.503-1, which implements ERISA § 503 (29 U.S.C. § 1133). The letter names the medical or vocational experts whose advice formed the basis of the denial under (j)(4), requests the claims file under (m), and puts the 180-day internal-appeal window on the record.

45 C.F.R. § 147.136

ACA appeal-rights language

On the substance, the plan’s formulary step-therapy rationale does not survive the Nondiscrimination standard at 45 C.F.R. § 147.136. The treating endocrinologist’s letter of June 4, 2026 documents prior failure on the preferred formulary step (glipizide-metformin with documented gastro-intestinal intolerance and a hypoglycemic episode on April 18, 2026), the American Diabetes Association Standards of Care 2026 recommendation that CGM is appropriate for type-2 patients on non-insulin therapies meeting the documented-risk profile, and the contraindication of further step-therapy on the formulary-preferred alternative. The plan must consider — not re-litigate — that documentation under its Nondiscrimination obligation. 42 U.S.C. § 18081 (the Nondiscrimination statute underlying 45 C.F.R. § 147.136) is hereby invoked.

Cited: 45 C.F.R. § 147.136; 42 U.S.C. § 18081

State statute

State-statute citation pattern

In the alternative, to the extent this plan is a fully-insured Texas, New York, or California plan, the controlling state adverse-determination statute applies: Tex. Ins. Code §§ 4201.354 (specific clinical criteria disclosure), 4201.155 (internal-appeal pathway disclosure), 4201.206 (external-review rights); N.Y. Ins. Law § 3214 (appeal of adverse determination); Cal. Health & Safety Code § 1371.35 (utilization review / grievance procedures). The state-statute ground is pleaded in the alternative and not as a substitute for the federal framework above.

Cited: Tex. Ins. Code §§ 4201.354, 4201.155, 4201.206

For Texas fully-insured plans, an adverse-determination letter must arrive with the specific clinical criteria used, an internal-appeal pathway, and a four-month external-review window — Tex. Ins. Code §§ 4201.354, 4201.155, 4201.206. Letters on fully-insured state plans cite the controlling state Insurance Code (or analogous N.Y. Ins. Law / Cal. Health & Safety Code) and lay the external-review review track on the record.

I reserve all available review remedies, including the four-month external-review window under 45 C.F.R. § 147.136(d), the right to the claims file under 29 C.F.R. § 2560.503-1(m), and the right to bring a civil action under ERISA § 502(a) (29 U.S.C. § 1132(a)(1)(B)) on exhaustion of internal and external review. Records and supporting clinical evidence are enclosed; please confirm receipt. Expedited review under 45 C.F.R. § 147.136(b)(3) is requested if the plan concludes this patient’s continued access to CGM supplies qualifies under the standard for serious jeopardy to health.

Respectfully submitted,

Priya R. Banerjee

Cited: 45 C.F.R. § 147.136; 29 C.F.R. § 2560.503-1; 29 U.S.C. § 1133.

Identifiers, member IDs, claim numbers, and street addresses in the sample letter above are fully redacted — every name is invented, and only the controlling statute / CFR / USC citations are real (those are public law).

What each annotation teaches

Three citation patterns to read for — and the framework each one belongs to.

State-statute citation pattern

Texas fully-insured plans are bound by Tex. Ins. Code §§ 4201.354 + 4201.155 + 4201.206 on adverse determination, internal-appeal, and external-review procedures. N.Y. Ins. Law § 3214 and Cal. Health & Safety Code § 1371.35 are the analogous state regimes.

ERISA procedural timing

Self-funded ERISA plans run through the Department of Labor claims-procedure rule at 29 C.F.R. § 2560.503-1, implementing ERISA § 503 at 29 U.S.C. § 1133 — the 180-day internal-appeal window is keyed to the Adverse Benefit Determination, and the claims-file right under (m) is the lever that surfaces the plan’s clinical experts.

ACA appeal-rights language

ACA marketplace plans are bound by 45 C.F.R. § 147.136 — internal appeal under (b)(2), four-month external review under (d), expedited review for ongoing treatment under (b)(3). The Nondiscrimination standard at 42 U.S.C. § 18081 constrains formulary step-therapy and utilization management.

02 · Draft yours

The next denial is the one the letter is built around.

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Denvow is template-and-tooling, not legal counsel. For denials that genuinely need litigation, an ERISA fiduciary complaint, or a state-court remedy, we recommend a licensed attorney in the relevant jurisdiction — and will say so when we see one.