Gastric By Pass Appeal Letter Free Download

Gastric By Pass

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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Gastric Bypass Surgery

Your name and address


Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment for this medical procedure, stating that it was not medically necessary and was cosmetic in nature.

My primary care physician [Physician Name] requested that I have this surgery who is very concerned about my health due to obesity. I am [age], [height] and [weight] for a body mass index of [BMI]. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over [enter BMI per physician for a man], or woman's exceeds [enter BMI per physician for a woman], that person is considered obese. Obesity contributes to a higher percentage risk in death at my present weight.

Due to my present weight, I am having significant adverse symptoms, including [list symptoms] which are negatively impacting my performance of daily activities [list activities such as sleep, work, social, etc]. I have made many, previous attempts to lose weight, but I have been unsuccessful. [Describe previous attempts for weight reduction].

I have exhausted all other alternatives to lose weight and I have been referred to having gastric bypass surgery as a proven method of losing this weight. Please reconsider your denial of this claim with the information I have included in this appeal letter. If you have any questions, please contact my primary care physician at [phone number] or my surgeon at [phone number].


[Insured’s Name]

Reference Sources:
Statement of medical necessity from the surgeon and/or primary care physician
Any additional supporting documentation