8/14/2019 Appeal From an Attorney

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(Date)

(Name)

Connecticut General Life Insurance Company (Cigna Healthcare)PO Box 29000

City, State 30359

Re: Patient Name

Indemnity Plan

Policy # 123-456-7890 / Group # N/A

Dear (Name of contact person at insurance company),

Please accept this letter as Patient Names appeal to Insurance Company decision

to deny coverage for laparoscopy-banded gastroplasty (procedure code 43843).

It is my understanding based on your letter of denial that this procedure has been

denied because:

Non-Covered Benefit

Patient Name has been diagnosed with morbid obesity. Dr. Primary Care

Physician states that, in his professional opinion, Patient Name will significantly benefit

from laparoscopy-banded gastroplasty. Please see the enclosed letter from Dr. PrimaryCare Physician that discusses Patient Names medical history and states the basis for his

opinion in support of this procedure. Also included please find correspondence from Dr.

Surgeon from Main Street Hospital in further support of the medical need of thisprocedure. Dr. Surgeon is a specialist in Bariatric Surgery. His letter discusses the

procedure in more detail. Also included are medical records, Ms. Patient Names personal

letter, evaluations from other health care providers, and clinical studies detailing theefficacy of this procedure. I am providing this information to you because I am concerned

you did not have all the necessary information at the time of your initial review.

Based on this information, we are asking that you reconsider your previousdecision and allow coverage for the procedure Dr. Surgeon outlines in his letter. The

treatment is scheduled to begin on August 21, 2001.

My client informs me that she and her physician have made several attempts to

appeal this decision. Ms. Patient Name also informs me that Insurance company claims it

has not received two mailed copies and two facsimiles transmissions of her appeal

. Please review the enclosed information carefully. It would be unfortunate for all

parties involved if litigation under the American with Disabilities Act (ADA), 42 USC 12101, et. Seq. were required to resolve this issue.

Should you require additional information, please do not hesitate to contact

Patient Name at 123-4567. Ms. Patient Name will look forward to hearing from you in

the near future.

8/14/2019 Appeal From an Attorney

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Sincerely,

Attorney at law

Cc: Primary Care Physician. MDSurgeon, MD

Insurance person, R.N.

Patient Name