Here is a sample appeal letter written for a woman with severe capsular contracture and a ruptured implant who was denied coverage for her breast implant removal surgery. For help editing your own appeal letter, contact us at email@example.com. Click here to download.
Breast Implant Removal Office
555 Smiles Way
Healthytown, DC 55555
April 6, 2018
XYZ Claims Department
167 Daisy Lane
Milwaukee, OK 12345
RE: Appeal for Denial of Claim Submitted by Jane Doe
Group/Policy number: 1425-2345-1234
Date(s) of service: February 31, 2018
Dear XYZ Claims Department:
I am writing on behalf of my patient, Jane Doe, to appeal XYZ’s decision to deny coverage for her breast implant removal surgery. I recommended the surgery because Ms. Doe has severe capsular contracture, which is causing her severe pain, restricting her movements, and interfering with mammography. In addition, her right implant is broken.
Your denial letter dated November 3, 2017, states that coverage for this procedure was denied because Ms. Doe’s “current condition does not meet the needed requirements and a bilateral breast revision is not medically necessary.” According to your letter, that determination was based on XYZ’s Coverage Criteria #567 and the details of her case. Your review concluded that because Ms. Doe has “not had breast cancer surgery or a breast injury,” you cannot approve the request for explant surgery.
We respectfully ask you to reconsider that decision. According to page 23 of my patient’s XYZ Medical Policy document (copy enclosed), Ms. Doe’s plan covers all “medically necessary” services that are not expressly excluded. Her plan does exclude cosmetic procedures; however, Ms. Doe’s implant removal is NOT a cosmetic procedure. Although Ms. Doe initially had the implants placed for cosmetic reasons, I recommended permanent removal solely to treat her present medical condition.
A review of XYZ’s Coverage Criteria #567 confirms my view that removal of her implants should be considered medically necessary. The guideline states:
“Removal of breast implants for any of the following conditions may be medically necessary:
– Broken or failed implant;
– Implant extrusion;
– Siliconoma or granuloma;
– Interference with breast cancer;
– Breast pain; and
– Painful contraction”
Ms. Doe meets several of the above-stated criteria. I diagnosed her with Baker Grade IV capsular contracture (i.e. “painful contraction”) in her left breast, which is causing her chronic pain, restricting her movements, and interfering with mammography. Because of the pain, Ms. Doe regularly takes pain medication. Additionally, the MRI detected that Ms. Doe’s right silicone gel implant has broken (failed).
Consequently, based on the aforementioned language of the XYZ Medical Policy document and XYZ Coverage Criteria #567, XYZ should consider Ms. Doe’s implant removal a medically necessary procedure. Surgical removal of breast implants is the standard medical treatment for severe capsular contracture. The surgery is not intended to improve her appearance, rather it is intended to relieve her pain and restore her functioning. There is no other equally effective treatment available to Ms. Doe that is more conservative or less costly. Without removal, Ms. Doe will continue to experience severe pain and restricted movement, and her capsular contracture will make future screening mammograms difficult, if not impossible.
Based on this information, I request that you reconsider your denial and approve coverage for Jane Doe’s breast implant removal surgery. For your convenience, I have enclosed copies of all Ms. Doe’s relevant medical records. If you need additional information, please do not hesitate to contact me at (111) 111-1111 or firstname.lastname@example.org.
Thank you for your immediate attention to this matter.
Dr. David Healthcare, Chief of Breast Implant Removal Operations
Ms. Doe’s XYZ Medical Policy
Ms. Doe’s Office Visit Notes from 11/21/2017
MRI Report from 12/10/2017
Ms. Doe’s post-operative report from 2/31/2018