Panniculectomy Appeal Letter Free Download


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Appeal Letter Displayed for Your Convenience

Health Symphony Appeal Letter

For Panniculectomy

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 an Panniculectomy, stating that it was not medically necessary and was {cosmetic in nature.} (please confirm denial reason).

{Confirm this statement with physician or change wording to match situation.}[Patient] was the recipient of gastric bypass surgery. [Physician Name] requested that the [Patient] have this surgery due to health concerns related to obesity. The patient was [age], [height] and [weight] for a body mass index of [BMI].

{Option 1} As a result of this surgery {weight loss}, the patient has (list pain areas i.e. severe lower back pain which is only relieved when the patient sits down or painful rashes that have existed under the skin fold of the stomach, include other symptoms such as severe itching, difficulty with movement, etc – select those that apply.) You will find enclosed with my appeal letter (2 or 3) other letters from board certified physicians that also state this procedure is medically necessary .

{Option 2} The requested surgery would be considered reconstructive and not cosmetic given these symptoms and should be covered by the health plan.

Please reconsider your denial of this medical procedure with the information I have included in this appeal letter. If you have any questions, please contact me [primary care physician’s phone number] or the patient’s surgeon at [phone number].


[Primary Care Physician or Other Physician’s Name]

Reference Sources:
Statement of medical necessity from the surgeon and/or primary care physician
Any additional supporting documentation
In the body of this letter include specific descriptions of pain you are suffering
Sometimes health plans request photos, your doctor can decide whether to include