This is a formal appeal of the denial dated [date], reference [number], for [service] for [patient]. The plan's criterion [quote the criterion] is met by [chart entry, date, page], and [next criterion] by [entry]. My physician's letter of medical necessity is enclosed. I request review by a physician in [specialty]. [If urgent:] Because delay would seriously jeopardize my health, I request expedited review. Please send me the complete claim file and the criteria relied on if you have not already done so.