Clinical Appeals of medical treatment decisions

Types of decisions you can appeal through our Clinical Appeals process

You can request a review of a decision that your health care team makes about your treatment or care. Here are some types of medical treatment decisions you can appeal through our Clinical Appeals process:

• If your provider should prescribe a specific medicine for you
• Whether you should receive a specific type of therapy

We also call these treatment decisions “medical determinations.”

Note: Do you want to appeal a VA decision about your health care benefits (like VA health care, CHAMPVA, dental treatment eligibility, or travel reimbursement)? You’ll need to use our decision review process instead. 
Learn more about choosing a decision review option

How to appeal a medical treatment decision

Contact your VA health care facility’s patient advocate. Patient advocates are highly trained professionals. They work to support the rights of Veterans and their families who receive care through VA. Your advocate will guide your written appeal request through the Clinical Appeals process. They’ll work with the facility’s chief medical officer and any other needed experts to review the medical treatment decision.

How to send your appeal request

Send your written appeal request as soon as you can to your facility’s patient advocate. You can find the name and contact information for your patient advocate on your facility’s website.

Find your facility’s website

What to include in your appeal request

• The decision you disagree with
• Why you disagree with the decision
• Any medical evidence (like personal provider medical records and published clinical studies) that you think support your disagreement

What to expect after you send your appeal request

First, you’ll receive a letter called a “Notice of Receipt of Clinical Appeal.” This letter confirms that your facility’s patient advocate has received your appeal request. 

After the patient advocate reviews your appeal request, they’ll determine the next step for your appeal:

• If you provided new medical evidence, the advocate may request that your health care team review their original decision again.
• If your appeal enters the Clinical Appeals process, your facility’s chief medical officer, or someone they designate, will review the appeal and any relevant medical records. If needed, they’ll ask other experts to help review the appeal, too.

You’ll then receive a final letter with the decision on your appeal. If you agree with the decision, we’ll consider the appeal closed. If you disagree with the decision, you can appeal the decision in writing to your Veterans Integrated Service Network (VISN) Office.

Find your facility’s VISN Office on our Veterans Health Administration website