Bariatric surgery appeal letter template
A free, fillable bariatric surgery appeal letter you can copy, complete, and send. It is built on the structure that actually wins bariatric surgery appeals, not a generic reconsideration request.
The bariatric surgery appeal letter template
Copy the template below and replace every bracketed field with your details. Keep it to one or two pages plus attachments.
[Date] [Your full name] [Your address] [Your phone] · [Your email] [Insurer name], Appeals Department [Appeals address from your denial letter] Re: Appeal of bariatric surgery denial Member: [Patient name] · Member ID: [Member ID] · Group: [Group #] Claim #: [Claim #] · Date(s) of service: [Date of service] Denial date: [Denial date] · Denial/reason code: [Code] To the Appeals Department: I am formally appealing [Insurer]'s [denial date] denial of [service or medication]. I request that the denial be overturned and the bariatric surgery approved. 1. The denial. [Insurer] denied this bariatric surgery stating, verbatim: "[paste the exact denial language from your letter]." 2. Why the denial is incorrect. [State, in one or two sentences, why the service is medically necessary for your condition, and answer the specific reason the plan gave.] 3. The controlling standard. [See the standard for this denial type below, then cite it here.] 4. The evidence. I am attaching: - A letter of medical necessity from my treating provider addressing each clinical criterion; - [Your supporting records: see the document checklist below]; - The clinical guidelines and records that support coverage. 5. My request. I request a full reversal of this denial and approval of [service or medication] within the timeframe required by law. If the denial is upheld, please provide in writing the specific clinical criteria used, the credentials of the reviewing clinician, and instructions for independent external review. Under 29 C.F.R. 2560.503-1 (employer plans) or 45 C.F.R. 147.136 (ACA plans), please also provide all documents and records relevant to this claim. Sincerely, [Patient name / authorized representative]
The controlling standard for bariatric surgery denials
Plans set written criteria, commonly BMI of 40 or more, or 35 or more with a qualifying condition such as type 2 diabetes, sleep apnea, or hypertension, plus documented conservative weight-loss attempts, a psychological evaluation, and a nutrition assessment. Some plans exclude bariatric surgery entirely, which is a benefit exclusion rather than a medical-necessity decision. Medicare covers bariatric surgery for beneficiaries meeting its criteria under National Coverage Determination 100.14. Criteria must be disclosed on request (29 CFR 2560.503-1(m)(8); 45 CFR 147.136).
What makes a bariatric surgery appeal letter win
Request the plan's bariatric policy. Assemble the BMI history from every visit, the dated notes from the supervised program, the psychological evaluation, and the nutrition assessment, and index them to each criterion. If the denial is a benefit exclusion, check the plan document; an exclusion is appealed on the plan language, not on medical necessity, and external review may not be available. For revision surgery, document the complication or the anatomic failure, since criteria differ from first surgery.
The letters that get overturned share a structure: they quote the denial, rebut the plan's specific criteria point by point, cite the controlling standard above, attach a treating-provider letter of medical necessity, and make a clear demand for reversal. Generic letters that simply ask the plan to reconsider do not move reviewers.
Documents to attach
- The denial letter naming the criterion not met
- BMI and weight history from every visit in the policy period
- Supervised weight-loss program notes with dates
- Psychological evaluation and nutrition assessment
- Records documenting comorbidities (labs, sleep study, blood pressure)
Skip the blank page
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Build my appeal free →Bariatric surgery appeal: frequently asked questions
my insurer says I did not complete a supervised diet. I did. What now?
The plan needs dated notes from each month of the program, not a summary letter. Gather the visit notes and index them to the policy's requirement in the appeal.
My my insurer plan excludes bariatric surgery. Can I appeal?
You can appeal on whether the exclusion applies to your procedure and whether the plan document says what the denial says. An exclusion is not a medical-necessity decision, and independent external review is generally not available for it.
What BMI does my insurer require?
Most policies use 40 or more, or 35 or more with a qualifying condition. The exact figures are in the plan's bariatric policy, which you can request in writing.
Is revision surgery covered by my insurer?
Often, when there is a documented complication or anatomic failure of the first procedure. Weight regain alone is treated differently by different policies. Get the policy and document the medical reason.