Health coverage can feel reassuring right up until a treatment, scan, surgery, or medication needs approval before it can happen. Then a simple phone call often turns into forms, waiting, and emails that seem to ask for the same information twice.
A well-written preauthorization request letter can make that process smoother. It gives the insurance company the medical details it needs while helping avoid delays that come from missing information or unclear requests.
Even though every insurer has its own process, a clear letter still carries plenty of weight. The samples below cover different situations, giving you ready-to-use examples that can be adapted to your own needs.
Sample Letters of Health Insurance Preauthorization Request
The right letter depends on the treatment, the urgency, and who is sending it. Some requests come directly from patients, while others are written by healthcare providers on the patient’s behalf.
1. Preauthorization Request for MRI Scan
Subject: Request for Preauthorization for MRI of the Lumbar Spine
Dear Preauthorization Department,
I am writing to request preauthorization for an MRI of my lumbar spine as recommended by my treating physician, Dr. Sarah Mitchell.
Over the past four months, I have experienced persistent lower back pain accompanied by numbness and tingling in my left leg. Conservative treatments, including prescription medication, physical therapy, and activity modification, have not relieved my symptoms. Based on my continued condition, my physician believes an MRI is medically necessary to determine the underlying cause and guide further treatment.
The requested procedure is scheduled at Green Valley Diagnostic Imaging on August 5, 2026. Relevant medical records, physician notes, and previous treatment history are enclosed for your review.
I kindly request prompt approval so the imaging can proceed without delay. Please let me know if additional documentation is required.
Thank you for your attention.
Sincerely,
Michael Turner
Policy Number: HN45892714
Member ID: 28461735
Phone: (555) 321-8821
2. Preauthorization Request for Elective Surgery
Subject: Request for Preauthorization for Arthroscopic Knee Surgery
Dear Claims Review Team,
I respectfully request preauthorization for arthroscopic surgery on my right knee as recommended by my orthopedic surgeon, Dr. Jennifer Collins.
Following an MRI and several clinical examinations, I have been diagnosed with a torn medial meniscus. Physical therapy, anti-inflammatory medication, and joint injections have provided only temporary relief. My physician has determined that surgery is the most appropriate treatment to restore normal knee function and reduce ongoing pain.
The proposed procedure is scheduled for August 18, 2026, at Riverside Orthopedic Center. Attached are the physician’s recommendation, MRI findings, office visit notes, and supporting medical documentation.
Please review this request at your earliest convenience so there is no interruption to my treatment schedule.
Thank you for your consideration.
Sincerely,
Daniel Brooks
Policy Number: HC73049518
Member ID: 19754120
3. Preauthorization Request for Specialty Prescription Medication
Subject: Request for Preauthorization for Humira Prescription
Dear Prior Authorization Department,
I am requesting preauthorization for Humira (adalimumab) as prescribed by my rheumatologist, Dr. Rebecca Allen, for the treatment of moderate to severe rheumatoid arthritis.
For the past three years, I have lived with persistent joint pain, swelling, and stiffness that significantly affect my daily activities and ability to work. Despite trying methotrexate, sulfasalazine, and several anti-inflammatory medications, my symptoms remain active. My physician has determined that Humira is now medically necessary because previous therapies have not provided adequate disease control.
Enclosed with this request are my physician’s treatment notes, laboratory results, previous medication history, and the prescription supporting this recommendation. These records demonstrate the progression of my condition and the medical need for this biologic therapy.
I kindly ask that this request be reviewed as soon as possible so treatment can begin without unnecessary delay. If further documentation is needed, please contact my physician’s office or me directly.
Thank you for your prompt attention.
Sincerely,
Angela Morris
Policy Number: HI45871629
Member ID: 35018472
Phone: (555) 483-9217
4. Preauthorization Request for Physical Therapy
Subject: Request for Preauthorization for Physical Therapy Services
Dear Medical Review Department,
I am requesting preauthorization for twelve physical therapy sessions following surgery on my left shoulder.
On June 28, 2026, I underwent rotator cuff repair performed by Dr. Nathan Cooper. My surgeon has recommended structured physical therapy beginning immediately to restore mobility, rebuild strength, and reduce the risk of permanent stiffness. Delaying therapy could slow healing and affect my long-term recovery.
The treatment will be provided by Summit Rehabilitation Clinic twice each week over the next six weeks. Attached are my surgical report, physician referral, rehabilitation plan, and recent medical records supporting this request.
I appreciate your timely review and approval so I can continue recovering according to my physician’s instructions.
Thank you for your consideration.
Sincerely,
Patricia Evans
Policy Number: HC84731506
Member ID: 60148293
5. Preauthorization Request for CT Scan
Subject: Request for Preauthorization for CT Scan of the Chest
Dear Insurance Authorization Team,
I respectfully request preauthorization for a CT scan of my chest as recommended by my pulmonologist, Dr. Kevin Hughes.
I have experienced persistent chest discomfort, unexplained coughing, and shortness of breath despite several weeks of treatment. Chest X-rays and routine testing have not identified the cause of these symptoms. My physician believes a CT scan is medically necessary to evaluate my lungs and surrounding structures more thoroughly.
Supporting documents include physician consultation notes, laboratory reports, imaging results, and the diagnostic order. The scan has been scheduled pending insurance approval.
I would appreciate your prompt review so the recommended diagnostic testing can proceed without interruption.
Thank you for your time and consideration.
Respectfully,
Thomas Richardson
Policy Number: HI26194085
Member ID: 47269158
6. Preauthorization Request for Chemotherapy Treatment
Subject: Request for Preauthorization for Chemotherapy Services
Dear Preauthorization Review Committee,
I am writing to request approval for chemotherapy treatment recommended by my oncologist, Dr. Emily Carter, following my recent diagnosis of Stage II breast cancer.
After completing all necessary diagnostic testing, my oncology team has determined that chemotherapy is an essential part of my treatment plan. Delaying treatment could reduce its effectiveness and may affect my overall prognosis.
Attached are my pathology report, biopsy findings, physician treatment plan, laboratory results, and all supporting medical records required for review.
I respectfully request expedited consideration of this application so treatment may begin as scheduled. Should you require additional information, my oncology team is prepared to provide it immediately.
Thank you for your prompt review.
Sincerely,
Melissa Johnson
Policy Number: HC91582473
Member ID: 58102964
7. Preauthorization Request for Sleep Study
Subject: Request for Preauthorization for Overnight Sleep Study
Dear Prior Authorization Department,
I am writing to request preauthorization for an overnight sleep study prescribed by my primary care physician, Dr. Laura Bennett.
For several months, I have experienced loud snoring, frequent nighttime awakenings, excessive daytime fatigue, and morning headaches. My physician suspects obstructive sleep apnea based on my symptoms and physical examination. An overnight sleep study has been recommended to confirm the diagnosis and determine the most appropriate treatment.
Previous lifestyle adjustments and changes in sleeping position have not improved my condition. Because untreated sleep apnea can increase the risk of high blood pressure, heart disease, stroke, and other health complications, my physician believes this diagnostic test is medically necessary.
Enclosed are my physician’s referral, office visit notes, medical history, and any supporting documentation required to process this request.
I kindly ask that you review and approve this request as soon as possible so testing can proceed without delay.
Thank you for your time and consideration.
Sincerely,
James Peterson
Policy Number: HC63821754
Member ID: 71483590
Phone: (555) 604-3178
8. Preauthorization Request for Home Healthcare Services
Subject: Request for Preauthorization for Home Health Care
Dear Medical Authorization Department,
I respectfully request preauthorization for home healthcare services following my recent discharge from Memorial Medical Center.
After undergoing hip replacement surgery, my physician has determined that skilled nursing visits and in-home physical therapy are necessary during my recovery. Due to limited mobility and a higher risk of falls, traveling regularly to outpatient appointments is not currently practical.
My treatment plan includes nursing assessments, wound care, medication monitoring, and physical therapy over the next six weeks. These services have been prescribed to support a safe recovery while reducing the likelihood of complications or hospital readmission.
Attached are my hospital discharge summary, physician’s orders, rehabilitation plan, and supporting medical documentation.
Please review this request at your earliest convenience so these medically necessary services can begin immediately.
Thank you for your consideration.
Sincerely,
Dorothy Wilson
Policy Number: HI74298163
Member ID: 63925147
9. Preauthorization Request for Durable Medical Equipment
Subject: Request for Preauthorization for Power Wheelchair
Dear Preauthorization Review Team,
I am requesting preauthorization for a power wheelchair as prescribed by my rehabilitation specialist, Dr. Steven Harris.
I have a progressive neuromuscular condition that significantly limits my ability to walk safely, even with the use of a cane or standard walker. My physician has completed a mobility assessment and determined that a power wheelchair is medically necessary to help me perform essential daily activities inside and outside my home.
The recommended equipment will improve my independence while reducing the risk of falls and related injuries. Supporting documentation includes the physician’s prescription, mobility evaluation, occupational therapy assessment, and recent medical records.
I respectfully request prompt approval so the equipment supplier can proceed with delivery and fitting.
Please let me know if additional information is needed to complete your review.
Thank you for your attention.
Sincerely,
Robert King
Policy Number: HC39186475
Member ID: 50417382
10. Preauthorization Request for Outpatient Mental Health Treatment
Subject: Request for Preauthorization for Intensive Outpatient Mental Health Program
Dear Prior Authorization Department,
I am writing to request preauthorization for participation in an intensive outpatient mental health treatment program recommended by my psychiatrist, Dr. Karen Phillips.
Following a comprehensive psychiatric evaluation, my physician has determined that structured outpatient treatment is medically necessary to manage my condition and reduce the likelihood of hospitalization. The recommended program includes individual counseling, group therapy, medication management, and regular psychiatric follow-up over the next eight weeks.
This level of care will provide consistent treatment while allowing me to continue meeting my family and work responsibilities. Enclosed are my psychiatric evaluation, treatment plan, referral, and supporting medical records for your review.
I respectfully request timely approval so treatment can begin on the scheduled admission date. Please contact my physician or me if any additional documentation is required.
Thank you for your prompt consideration.
Sincerely,
Olivia Martin
Policy Number: HI81529647
Member ID: 42691853
Wrapping Up
A strong health insurance preauthorization request letter keeps the focus where it belongs, on the medical need for the requested treatment or service. Whether the request is for surgery, diagnostic testing, prescription medication, rehabilitation, or specialized care, including the physician’s recommendation, relevant medical history, supporting records, and insurance details gives the reviewer the information needed to make a decision more quickly.
Each of these samples can serve as a starting point for your own letter. Adjust the medical details, dates, healthcare providers, and policy information to fit your situation, then include any documents your insurer requests. A clear and complete submission often reduces back-and-forth questions and helps keep your care moving forward without unnecessary delays.