Does anyone have a sample of a reconsideration letter for insurance payment

I had my surgery in Nonember of 2001. In January of 2003 I had a body lift in which the insurance company said that I didn't need to sumit for pre-approval because it was done outside the U.S, now they only paid a portion, after speaking with them they said I can send a letter of reconsideration and all my supporting doucments.

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