Sample Insurance Appeal Letter
Below is a sample letter to assist patients who have been denied coverage by their insurance companies in receiving reimbursement/coverage for compression bandages or garments. Be sure to read it carefully and fill in the blanks as necessary, customizing it to your specific situation. Have your physician sign and send it, retaining a copy for your records. Good luck and let us know how it goes!
To: Medical Affairs Appeals Dept.
From: [Doctor], M.D.
Subject: Physician Appeal of Denial of Coverage for [Name of Garment or Description of Bandage that was Denied]
I am filing an appeal of an Administrative Adverse Decision on behalf of [Patient's Name] for the following adverse [Medical Provider] decision that is included as an attachment to this memorandum:
Re: [Patient's Name]
Member Number: [Patient's Medical Number]
Group: [Medical Group]
Reference #: [Denial Letter]
[Patient's Name] is under my care for chronic Lymphedema (LE) (ICD-9-CM 457.0/457.1/757.0) that causes severe swelling (and pain) in [his/her] [legs and feet/arm(s)/torso/groin]. I have referred [Patient's Name] for the approved treatment for [Patient's Name]'s diagnosed lymphedema to the [Name of Department, Clinic or Center]. This clinic is [Qualification of treatment center to which Patient was referred, e.g., "nationally recognized and respected for treatment of LE and is under the leadership of "John Doe, MD", or "staffed with therapists trained and certified in the Vodder (or Foeldi or Casley-Smith or LeDuc) method of lymphedema treatment."]
The treatment for LE is officially known as Complete Decongestive Therapy (CDT). As documented in the enclosed materials, CDT comprises a multi-phasic treatment program. One of the essential treatment modalities is the regular use of compression garments/bandages/devices, as compression is required in order to maintain the reduction of high protein edema achieved with Manual Lymph Drainage (MLD). MLD, one of the components of CDT, is performed during the clinical treatment phase and, in a simplified form as a component of self-care in the home treatment phase. After the initial intensive program, patients must wear compression garments daily and compression bandages or non-elastic compression garments or devices nightly on the affected body areas. Although it does vary to some degree, individuals with lymphedema should not remove compression from the affected area for any extended period of time, particularly when they are engaging in any physical activity such as standing or walking, or while performing therapeutic exercises as part of CDT.
The following enclosed medical journal articles describe the CDT standard treatment for LE:
- "Workgroup III: Diagnosis and Management of Lymphedema", Cancer, Vol. 83, No. 12, December 15, 1998, (Supplement), American Cancer Society Workshop on Breast Cancer Treatment-Related Lymphedema, New York, NY, February 20-22, 1997, pp. 2882-2885.
- International Society of Lymphology, Executive Committee: "The Diagnosis and Treatment of Peripheral Lymphedema, 2009 Consensus Document of the International Society of Lymphology", Lymphology, 2009; 42:51-60.
- NLN Medical Advisory Committee: "Position Statement of the NLN. Topic: The Diagnostic and Treatment [of Lymphedema]" February, 2011.
Compression bandages, compression devices and compression garments are an integral part of the treatment for LE. Unless [Patient's Name]'s coverage policy excludes treatment of Lymphedema, [Patient's Name] must be provided all parts of the CDT treatment. Compression garments, devices and bandages are particularly important during the self-treatment phase following clinical treatment.
As cited in the medical literature, if left untreated, LE may result in several severe consequences, including fibrosis, joint immobility, amputation and life-threatening infections that may require repeated hospitalizations for intensive intravenous antibiotic therapy. Failure to provide [Patient's Name]with proper treatment, including compression garments, devices and bandages, predisposes him or her to these serious consequences. (Prior to being sent to the [Referred Treatment Center], [Patient's Name] experienced several onsets of lymphangitis/cellulitis, a severe infection resulting from his/her LE disease, requiring multiple extended hospitalizations.) [Include specific dates and treatment details]
Based on the available medical literature on [Patient's Name]'s LE condition, I am filing this physician/health care provider appeal request, specifically requesting that you provide him/her with the required [Name of Garment or Description of Bandage that was Denied], as I personally prescribed, to treat [his/her] advanced Lymphedema condition. In addition, I would like to emphasize that coverage of necessary compression bandages and garments must be ongoing. Garments are worn during waking hours and bandages or non-elastic compression devices at night in order to maintain the affected limb. Due to this frequent wear and necessary laundering, garments and bandages have a limited life span. Therefore, each patient must have two sets of bandages and/or garments at all times, both of which must be replaced every six months. Thank you for your prompt attention to this request.
[Physician's Name], M.D.
- [Description of Treatment Plan/Treatment Protocols, e.g.: Lymphedema-An Information Booklet by Saskia R. J. Thiadens, NLN; Lymphedema Handbook, Kaiser Permanente; or treatment program information from your treatment center.]
- [Date] adverse decision for coverage of Jobst compression garments for [Patient's Name], submitted by [Medical Provider].
- "Statement of Medical Necessity" for [Name of Garment or device, or Description of Bandage system that was Denied, e.g., Custom-Made to Measure Compression Stockings, provided by your medical supply company].
- Documents referred to in text.