Sample Appeal letter

I was denied by my insurance company a few weeks ago, and I sent this appeal letter last week, I received a reply the next day that I have a hearing in 2 weeks. I copied some of the info from other web pages dealing with WLS appeals off the net. And the rest I just filled in the info. I'm not sure if its a good letter, but I hope it helps. I think compared to a lot of the letters I've seen its to the point and deals with the company's policy as well as my own situation. here it is: Xxxxxx Medical Management Department XXXXx N. Xxxxxx St., Suite Xxxx Xxxxxxxxxxx, IN 4xxxx Attn: Clinical Appeals Review Subject: Appeal of Denial of medical coverage for Bariatric Surgery Re: Xxxxxxx X. Xxxxxxx Member ID# xxxxxxxxxx Dear review board: I am writing this letter to formally appeal your decision to deny bariatric weight loss surgery as communicated to me in a letter from Xxxxxx Health Organization, dated September 17, 2004. On page twenty-eight (28) of my policy, under the heading of Morbid Obesity Services, it states: ? "Services and supplies include: Non-experimental weight loss surgery for Morbid Obesity when provided that non-surgical treatment, supervised by your physician for at least eighteen (18) consecutive months, has been unsuccessful. Members who meet specific benefit criteria may qualify sooner than 18 months." Furthermore, Xxxxxx's Winter 2003 publication of Provider Perspective, volume 7, number 1 lists Xxxxxx policy guidelines for bariatric surgery patient selection criteria. Section 2(d) of this criteria states: ? "BMI > 60 with comorbidities: requires 6 consecutive months of documented compliance with comorbidity-related medical therapy, i.e., hypertension, diabetes, etc., with no medical weight loss therapy required." Additionally, Section 2(e) of the above-mentioned criteria states: ? "At the plan's discretion. A member at very high risk for obesity-associated mortality and morbidity may be considered for surgery without documentation of medical weight loss therapy." During my initial request for bariatric surgery, my Body Mass Index (BMI) was incorrectly listed as 59.42 (Height 68 inches - weight 393.9 lbs.). I was weighed and measured at St. Vincent's Bariatric weight loss center today with shoes off and I was correctly listed with a BMI of 62.9, (Height 67 inches - Weight 404 lbs.). This correct information has been documented and sent to your office by the staff at St. Vincent's bariatric center. At that level of BMI, I fall into the super obese category. I have tried every diet out there and despite my considerable efforts, I haven't had any long-term success with weight loss. Instead, I have only gained weight over time and in turn have developed physical symptoms that are becoming harder and harder to effectively manage. I live with considerable back pain from carrying all of my weight around. I am unable to walk, except for short distances and this greatly effects my life and limits what I am able to do physically. My knees and feet hurt and I have difficulty going up and down the stairs in my house. I have been told that this will most likely go away with weight loss. These are just some of the physical symptoms that I deal with during the course of my day. According to the National Institute of Health, I have a mortality rate that is 1200% greater than others of the same ages who are of normal weight. It is likely that I will develop serious complications in the future. I have an increased risk of heart disease, as well as cancer. These complications would cost the company far more than the cost of gastric bypass surgery. My type II diabetes compounds the risk of heart disease even further. My father has a history of myocardial infarction to include surgical implementation of a stint. My mother has high blood pressure and both my maternal grandmother and grandfather had heart attacks, of which, my grandfather died. I currently take 30 mg of Actos daily to control my diabetes. I am on Lasix to attempt to control constant edema in my legs as a result of being super obese. According to my PCP, I am 6 months to 2 years away from requiring insulin. I have had 5 instances of acute cellulitus requiring hospitalization twice, most recently in July of 2004. It makes sense economically for Xxxxxx to provide the surgery before I suffer from any additional life threatening diseases. Therefore, having been diagnosed as a type II diabetic by Xxxxx X. xxxx, M.D., FAAFP, in February 2004, and having been treated consecutively each month since February, and given that I have a BMI of 62.9, with comorbidites, I clearly am at "very high risk for obesity-associated mortality and morbidity," and meet the requirements listed by Xxxxx for bariatric weight loss surgery. Thank you for your time and consideration. Sincerely, Xxxxxxx X. Xxxxx CC: Xxxx X. Xxxxx, M.D., F.A.A.F.P. Xxxxxxxxx Xxxxxx, M.D. Xxx XXXXX, Acting Commissioner, Indiana Department of Insurance XXX XXXXX, Consumer Services Division, Indiana Department of Insurance

It seems pretty good. Look at www.obesitylawyers.com there are a few samples and some do's and dont's on there

Laura: I see you and Ellen tout Gary's website here on OH all the time. Is it not obvious to you, and hopefully others, that he PLAGERIZED Roberta's "Do's and Don't list of Appeal Writing"? And may I add, he didn't write it as well as she did. She's been posting her list on this site and others for almost 2 years. Gary just added this to his website within the last few months. Coincidence? I think not. Towanda

HI LAURA, WHEN IS YOUR SURGERY? YOU MUST BE VERY EXCITED! DID GARY WIN YOUR APPEAL? I THINK WE WOULD ALL LOVE TO HEAR YOUR STORY, YOU SHOULD UPDATE YOUR PROFILE.

Tim, I really like that you quoted your plan wording. However, one thing is missing...the reason you were denied. If you were denied due to medical necessity, this is a good letter. If the reason for denial was something else, you needed to address the specific reason given in the letter from your insurance company. BTW, your insurance company seems the most reasonable of all the plans I've seen out there. I hope we will be hearing the magic word "approved" in the very near future. Fight the good fight! Roberta