Breast reconstruction appeal letter template
A free, fillable breast reconstruction appeal letter you can copy, complete, and send. It is built on the structure that actually wins breast reconstruction appeals, not a generic reconsideration request.
The breast reconstruction 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 breast reconstruction 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 breast reconstruction approved. 1. The denial. [Insurer] denied this breast reconstruction 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 breast reconstruction denials
The Women's Health and Cancer Rights Act of 1998 requires group health plans and insurers that cover mastectomy to also cover reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications including lymphedema, in consultation with the patient and physician (29 U.S.C. 1185b; 42 U.S.C. 300gg-52). Medicare covers reconstruction after mastectomy as well. Plan criteria for staging and revisions must be disclosed on request.
What makes a breast reconstruction appeal letter win
Cite the Women's Health and Cancer Rights Act by name and section in the appeal, and attach the mastectomy operative report and the surgeon's letter connecting each procedure to reconstruction or symmetry. The law contains no time limit for reconstruction; if the plan applies one, ask for the plan language. Ask the surgeon's office to confirm the procedure and diagnosis codes reflect reconstruction. Complications and lymphedema treatment are expressly covered.
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 with the reason stated
- Mastectomy operative report and pathology
- Surgeon's letter linking the denied procedure to reconstruction or symmetry
- Photographs or clinical notes documenting asymmetry or complications where relevant
- Plan document language on reconstruction
Skip the blank page
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Build my appeal free →Breast reconstruction appeal: frequently asked questions
my insurer called my reconstruction cosmetic. Is that allowed?
If the plan covers mastectomy, federal law requires it to cover reconstruction, symmetry procedures, prostheses, and complications. Name the Women's Health and Cancer Rights Act in the appeal and attach the mastectomy records.
It has been three years since my mastectomy. Is it too late for my insurer to cover reconstruction?
The federal law sets no deadline for reconstruction. If the plan applies one, request the exact plan language and appeal on it.
Does my insurer have to cover surgery on the other breast?
Yes, where it is needed to produce a symmetrical appearance after mastectomy, under the same law.
My revision was denied. Is a revision covered by my insurer?
Revisions that are part of completing reconstruction or treating complications fall within the law. The surgeon's letter should state which.