My appeal letter sample

I know when I was denied and needed to write a letter to my insurance company, I was seeking sample language as a starting point.  Based on the responses from many people here, I am providing what I sent yesterday.  Not sure what the outcome will be but wanted to be helpful:

Thank you for your speedy reply regarding my request to receive medical coverage for the costs of lipectomy and panniculectomy.  Unfortunately, I believe the denial was based on a lack of complete information in order to make your decision.  Thus, I would like to appeal the decision providing a more robust explanation of why this is a medical necessity rather than a cosmetic procedure.

 

1.        Physiological malfunction.  Unlike a cosmetic procedure, which by definition has only a side effect of improving the physicaliological appearance, this procedure is indeed reconstructive surgery because the physiological function of the body which is impacting me in the following ways:

a.       Recurrent and painful rashes that require antibiotics.  I have used a variety of creams and other remedies trying to resolve the issue but it has not responded to these manners of conservative treatment.  Over the course of time, the rash has caused open fissions that require me to lie on my back because the tension of the stomach pulls open the sore causing an immense amount of pain. 

b.      History of surgeries that over time weakened when presented together leading to the need of reconstructive surgery due to the excess of medical necessity as a result of the healing process:

                                                               i.      Two  pregnancies

                                                             ii.      Obesity with excessive weight loss resulting in panniculus (abdominal "apron" of superficial fat)

                                                            iii.      Panniculitis with dermatitis, which has included a history of infection of the abdominal wall and medication was prescribed

                                                           iv.      Radical hysterectomy surgery that resulted in cutting the muscle of the stomach wall for the procedure

                                                             v.      Gall bladder surgery and appendectomy that also resulted in cutting into the area that supports the wall.

2.        Back pain.  The condition causes excess pain and worsening of my degenerative/post-surgical condition.  This has aggravated my lumbar pain. I find it difficult to stand or walk for more than 20 minutes at a time without pain.  I have difficultly lifting, reaching, bending and sitting for prolonged periods of time due to the excess tissue.  The stress has lead to headaches that last for weeks in which no treatment has been found. 

 

 In searching for a more conservative treatment, I have sought out the help of a neurologist, had a MRI looking for new solutions, and taken a variety of medications from muscle relaxers, pain relievers, and opiants.  The result has not been an improvement in quality of life, less sick time, or pain.  Simply continuing to treat this symptom alone would quickly exceed the cost of the proposed surgery, which would result in less pain.

3.       Deformities associated cause an inability to exercise and impaired ambulation as a result of the pannus interfering with activities of daily living.  I have two young children and I am a single mother, which requires me to be the sole caretaker of their needs.  I need to have the ability to stand long enough to go to the grocery store, the ability to sit in a car without pain to transport them, the ability to bend over to do things like tie their shoes, assist with hygiene and other caretaker duties.  Currently, my condition limits these basic every day activities. 

4.       Inability to perform my job without pain.  As the sole provider for my family, an inability to work will significantly impact our lives.  Because of my responsibilities at work, it is an essential function to be able to be mobile for travel.  Currently, I must make a decision between being foggy with pain pills to perform my function impairing my judgment or trying to move through an airport in such intense pain from the stress of either open wounds or back pain from stress caused on the spine from this deformity.

 

As you can see, I sought out much medical advice and treatments prior to agreeing to consider reconstructive surgery for a solution to my condition.  While I may receive some cosmetic benefits from the procedure, it is the relief of unusual high amount of pain and chronic conditions that keep me from re-establishing normal activities.  I would be open to any treatment that would solve these issues, but unfortunately this appears as a last result.

 

From a business point of view, I know your company is concerned with the costs of surgery and my hope is that this investment from UHC will result in a reduction of payments as a result of these issues.  In reviewing my documentation ranging from medications to doctor visits, we will certainly exceed the cost of this surgery as I look to eliminate the pain, rash and inability to work within the year if you take into account pharmacy benefits, lab costs, physician consultations and other work associated to curing or stabilizing the chronic problems.

 

In a review of court records where such civil actions were filed in a court of law, I was surprised that several judges awarded in favor of the plaintiff for such conditions as I have illustrated here.  Indeed, the attorney and court costs would also exceed the benefits requested by UHC and neither the patient nor UHC would benefit from that next action due to costs and the risk of a more severe condition emerging from prolonging the action to resolve the medical necessity of this procedure.

 

I hope I have successfully demonstrated the medical necessity of this procedure and UHC now has a better understanding of the differentiation between what may be a cosmetic surgery vs. the medical necessity of my current state.  A review of my filings with UHC should easily provide the documentation to my case.

I was denied my first time as well. What the plastic surgeon told me to do is to get the skin rashes documented at least for 4 consecutive months. It is embarrassing to go see your doctor regarding it, but talk to your doctor and see what happens. Most doctors don’t like to see you for such things, but that is the best way to go. Explain to your doctor that you need this type of documentation for the surgery. If they see that you have had these rashes over a period of time, you will have approval in no time.  Once approved, they go back to the day you first applied for plastic surgery and it is one year from that date. I have Anthem Blue Cross & Blue Shield and they ended up covering it.  Good Luck!