Download "Gastric By Pass Appeal Letter" Word Document
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 #:
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].
Statement of medical necessity from the surgeon and/or primary care physician
Any additional supporting documentation