Appeal letter: frequency limit denial

An appeal letter template for a dental claim denied under a frequency limit when the dates were counted wrong or another office's claim was wrong.

Updated November 11, 2026

The denial

The plan denied the service because the plan's limit (for example, two cleanings a year or one set of bitewings a year) had already been reached.

Why plans deny it

Another office billed the same service, and the plan counted it.
The plan counted by calendar year when the plan year runs differently, or the reverse.
A visit was coded as this service by mistake, at your office or elsewhere.

Is it worth appealing?

Worth appealing only when the count is wrong: a wrong date, a wrong plan year, or a claim that shouldn't count. If the limit was truly reached, the patient owes the fee.

What to send with the letter

The claims history from the portal, with the dates the plan counted
The page of the benefit summary that states the limit and how it's counted
If another office's claim was wrong, anything that shows it, such as a corrected claim
A copy of the explanation of benefits

The letter

Paste it into your own letterhead and fill in the [brackets]. This page has no fields: nothing about the patient is typed here.

[Office name] [Office address] [Office phone] | [Office email] [Date] [Insurer name], Appeals [Insurer appeals address or fax] Re: Appeal of claim [claim number] Patient: [patient name] | Member ID: [member ID] | Date of birth: [date of birth] Subscriber: [subscriber name] | Group: [group number] Date of service: [date of service] | Procedure: [code] [service], date of service [date] Dear Appeals Reviewer, We are writing to appeal the decision on the claim above, on behalf of our patient [patient name]. The plan denied this service under its limit of [the limit, for example "two per calendar year"]. The plan counted earlier services on [dates the plan counted]. [Pick one: The plan's benefit year runs from [month] to [month], so the service on [date] falls in the prior benefit year. / The claim on [date] was for [what it really was], not this service, and has been corrected. / Our records show no service on [date].] Counted correctly, this is the patient's [first / second] service in the period, within the limit. Please review the enclosed records and reprocess the claim for payment under the patient's benefits. If you need anything else, call [contact name] at [phone]. Sincerely, [Dentist name], [DDS or DMD] NPI [NPI number] Enclosures: claims history, benefit summary page, explanation of benefits

Before you send it

Send it before the deadline. The denial notice has to say how long you have and how to appeal. Employer plans that follow federal benefit claim rules give at least 180 days.
Send it to the appeals address or fax on the explanation of benefits, not the claims address.
The patient, or someone they authorize, has the right to appeal. Offices often send it for the patient; some insurers first ask for the patient's signed authorization form.
Keep a copy of everything you send and the date you sent it. If the appeal is denied, the plan has to explain why in writing.

For how plans pay this service and what to check before treatment, read the cleanings billing guide.

A starting point, not legal advice. The plan's documents and the insurer decide what's paid.

CDT is a registered trademark of the American Dental Association. Tabruns is not affiliated with or endorsed by the ADA. The descriptions here are our own plain-English summaries, not the ADA's official wording; use your current CDT manual or practice software for the official code set.

Sources

Read November 11, 2026. Where a source describes one insurer's plans, we say so.

Get the patient's share in dollars, from the benefits page

Most of these denials can be seen coming from the benefits page. Tabruns reads the coverage, deductible, yearly maximum, waiting periods and frequency limits from the insurer's portal and works out what the patient owes. Patient details stay on the office computer.

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