Sample Appeal Letter from Surgeon/Patient to Insurance Provider

Your Full Name
Your Full Address
Your City, State and Zip
Your Phone Number with Area Code

Current Date

Insurance Provider’s Name
Insurance Provider’s Address
Insurance Provider’s City, State, Zip

Dear Insurance Provider (insert name of insurance provider contact),

I am appealing your decision for denying my medically needed weight-loss surgery. My height and weight are (height) (weight) and my BMI is (BMI). As statistics show and as medical doctors, you must be aware that diet and exercise help, but as a long term resolution to permanent weight-loss only 5 percent of people succeed. I am well aware of the risks with this surgery, but I believe the risks of being severely obese outweigh the risks of surgery.

I am (age)-years-old and have been overweight since I was about (age)-years-old. I have been on diets my whole life, having some success, but would always gain the weight back I lost, plus more. I will list the diets I have been on, but never kept any documentation because I could not have known at the time the insurance company would require it. Nor did I know that until this fairly new surgery even became an option for me, I would have to document weight-loss before getting the surgery.

  • Weight Watchers
  • Nutri–Systems
  • Schick weight-loss clinic (to the extreme of being shocked when eating bad foods)
  • Quick weight-loss clinic
  • Susan Powter book and diet
  • Atkins
  • Richard Simmons diet and exercise tapes
  • Cyber Vision behavioral modification tapes
  • Medically supervised diet and shots with a psychiatrist
  • Cabbage soup diet
  • Redux pills, under a medical doctor’s care
  • Overeaters Anonymous
  • Slim Fast
  • Hypnoses
  • Xenical
  • Gym
  • Protein Power Book Diet

(List all diets and weight-loss products used. If possible, include documentation.)

Currently, I am being monitored by my doctor, not necessarily being weighed once a month, but keeping a close eye on me. Again, I did not know it was required by my insurance for approval of the surgery.

I am not quite sure of how many years I have had (name of insurance company) insurance, but it has been many years for sure, much before they changed their requirement for documented medical weight-loss. I have attached some of my medical records that I feel are pertinent to weight-loss.

I have many co-morbid diseases, such as (high blood pressure, high cholesterol, poor circulation, acid reflux, pains in my joints and now have been diagnosed with diabetes, sleep apnea and asthma). I am on Cardizem, Accupril, HTCZ, Synthroid, (for goiter), Zantac, Naproxen, Advair and Albuterol inhalers and soon to be on a CPU machine.

(Discuss everything about how morbid obesity affects your life. Below, please find examples.)

Being severely obese puts a strain on everything I do. I cannot walk very far without getting out of breath, I cannot tie my shoes, fit in small seats whether in airplanes, seats in an office waiting room, theater, ball park or restaurant, wherever they may be. I am embarrassed of what I look like. I lack self confidence. I am not functioning to my full potential at work. I am always tired to the point of falling asleep at my desk. It takes me twice as long to do many things. I have no energy. I want to be more active and be able to do the things normal sized people do. I do not want to die. I know this surgery will be a life saver for me. Please reconsider your decision and save my life.

Sincerely,

Your Full Name



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