The letter below is a sample of an effective appeal from a patient that was denied bariatric surgery. In this case the patient was denied gastric bypass surgery.
Before writing your letter keep the following in mind.
- Do not lose the letter that your insurance company sent you telling you that you were denied! Most letters of denial include a contact name or phone number. You will need this for the appeal letter. And the letter will clearly state why you were originally denied!
- You should also either call your insurance company or be able to find an address to send the appeal letter on the letter of denial or by calling your insurance carrier.
Letters of Appeal are typically sent to a different address than the normal address listed on the insurance carriers web site. Don’t let your appeal letter get stuck in mail limbo!
Sample Letter of Appeal For Gastric Bypass Surgery
Date: June, 20012
Name of Insurance Company (Blocked out for confidentiality)
Name of Insurance Company Contact Person Listed in the Denial Letter or other Appropriate Contact
Address of Insurance Company
City, State, ZIP Code of Insurance Company
Re: Claim Number – 5552233344, Lap Band Procedure Denial
Group Number: G124444433
Policy Number: 532452-21391
I am writing this letter to appeal your decision to deny my Gastric Bypass surgery with Dr. ______.
I received the letter that (insert insurance company name) sent on (insert date). I have included a copy of that letter for your reference. The letter states that I have not met the criteria of “5 years documented morbid obesity.” I am currently 35 years old and have been at least 100 pounds overweight since I was 18. Although I haven’t had annual check-ups with my Primary Care Physician, the data I sent did show that I was morbidly obese for every visit. I have regularly had weigh-ins at my Ob/GYN. I have attached copies of those visits which clearly show that I was morbidly obese every year for the last 5 years.
I have also included the original documentation showing that I meet all other criteria outlined by your policy for gastric bypass surgery. Along with that I have included recent studies that show that my specific comorbidities, severe sleep apnea and Type 2 Diabetes, have greater than 70% and 80% chance respectively of being resolved.
Based on the data included I hope that you will reconsider coverage for gastric bypass surgery. I have surgery scheduled with Dr. _________ for August 20, 2012. Your prompt attention is greatly appreciated.
City, State ZIP Code
Although it might not seem like it, most insurance companies do cover bariatric surgery. Be vigilant! And don’t give up.