A Successful Sample Appeal Letter to Obtain Insurance Coverage for Plastic Surgery After Rapid Weightloss

This is my timely written appeal request in response to [insurance company's name] denial of coverage for a proposed abdominoplasty and proposed brachioplasty [or whatever procedure sought] dated ******.

[insurance company's] decision to deny the proposed abdominoplasty was based on two criteria per the denial letter. 1) not indicated that the abdominal fold hangs to or below the level of the pubis and 2) causes chronic skin inflammation, infection, and chafing that consistently recurs over three months while receiving appropriate medical therapy. A copy of the original decision letter is attached for your review and file. [please note what the insurance company's denial is based upon]

In the original request, pictures were submitted with regard to my abdominal fold. The pictures taken in [date] by Dr. [plastic surgeon name]'s office, indicate the abdominal fold does hang below my pubis. Dr. [plastic surgeon name] a plastic surgeon, informed me in my consultation that I have approximately seventeen to twenty pounds of excess skin hanging due to my 240 pound weight loss (original weight in August 2004 was 402lbs. to current weight of 162 lbs).

My excess abdominal skin causes chafing which results in both skin rashes and sores. I have received medical attention for this. I am careful to keep my abdominal area dry and clean per doctor's instructions, but get the skin irritation regardless. Aside from the skin problems caused by my abdominal fold is the constant worry that the sores will become infected and require further medical attention. Attached please find notes from my primary physician documenting my chronic skin rashes below my stomach and arms caused by constant chafing. I have attempted to treat these skin problems through medical therapy to no avail.

[insurance company] denied my request for brachioplasty surgery stating that there is no functional impairment which can not be improved without surgery. Please note that I have chafing of my excess skin on the underside of my arms (which hang low as seen in the photographs) as well as chafing on my rib cage from where the excess arm skin rubs against my torso when I walk. I have also snagged my hanging arm skin in cabinet doors, doorknobs, bushes, and have torn the skin reaching over items while performing household tasks such as cooking meals, gardening, and doing laundry. I feel that my arm skin does in fact create a functional impairment for me in performing my daily tasks. It is burdensome and is terribly painful when the skin gets snagged and rips. This could in fact be improved with the removal of this excess skin, which is significant in amount.

Please contact me with any questions you may have. I have lost a significant amount of weight (240 pounds) and feel these conditions could be improved with appropriate removal of my excess skin from both my stomach and arms. This request is not cosmetic in nature, it is medically indicated. The supporting documentation is attached for your review and file.

- end letter
- include your name, claim information, and contact information

Please note that this is not legal advice and should not be construed as such. However, this letter did result in the successful coverage of plastic surgery which is listed under my insurance as exclusionary. It is extremely difficult to get insurance to cover cosmetic procedures, especially once they have denied coverage. I was approved upon appeal. I hope this aids some of you in the pursuit of your weightloss goals and personal improvement.