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Appeal Letter: Surgery Denied by Insurance

Use this template when your insurer denied coverage for a surgical procedure citing medical necessity. Applies to elective and non-elective surgeries including orthopedic, general, and cardiac procedures.

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Key Arguments to Make

  • ✓The surgery was recommended by a board-certified specialist after conservative treatment failed
  • ✓Published clinical guidelines from relevant specialty societies support surgical intervention for this diagnosis
  • ✓Delaying surgery poses documented clinical risks including disease progression or permanent disability
  • ✓The insurer's clinical criteria are inconsistent with accepted medical standards

Appeal Letter Template

Customize the sections below with your personal details. Replace text in [brackets] with your information.

Sample Appeal Letter — SurgeryPersonalize This Letter →
To: [Insurance Company Name], Appeals Department
Re: Appeal of Claim Denial — [Your Name] — Member ID: [Member ID]
Date: [Today's Date]
Opening

I am writing to formally appeal the denial of coverage for [Surgery Name] ordered by [Provider Name] on [Date]. The denial reference number is [Denial Reference]. This surgery is medically necessary and I request immediate reconsideration.

Medical Necessity Statement

I have been diagnosed with [Diagnosis] and have undergone [duration] of conservative treatment including [treatments]. Despite these measures, my condition has not improved and my treating surgeon, [Provider Name], has determined that surgical intervention is the appropriate next step.

Clinical Support

[Relevant specialty society] guidelines support surgical treatment for patients meeting the criteria I satisfy: [list criteria]. I have enclosed a Letter of Medical Necessity from my surgeon detailing my specific clinical presentation and the rationale for surgery.

Closing

Continued denial of this surgery risks [specific clinical consequences]. I request reversal of this denial within the statutory appeal deadline. If my internal appeal is denied, I will pursue Independent External Review.

Sincerely,
[Your Name]
[Phone] · [Email]

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