These are templates, not legal advice. Each letter is a composite drafted by Counterclaim from publicly available appeal patterns and federal/state statutes. The bracketed placeholders ([PATIENT NAME], [DATE], etc.) must be replaced with your real facts. None of these letters reflect a real patient. Counterclaim is not a law firm. For a fully personalized, adversary-tested appeal generated from your specific denial letter, use the Counterclaim AI generator on the home page.
How to use these templates
- Identify the template that most closely matches your denial (DME, mental health parity, etc.).
- Copy the template using the copy button.
- Replace every bracketed placeholder with your real facts - patient name, DOB, member ID, plan name, claim/denial reference, dates, CPT/HCPCS/ICD-10 codes, treating physician's name and credentials, specific clinical facts.
- Verify every statutory citation against the law actually applicable to your plan type (ERISA self-funded vs. fully insured vs. individual marketplace) and your state.
- Attach all relevant exhibits: denial letter, EOB, treating physician's letter of medical necessity (see our template), medical records, plan coverage policy, peer-reviewed literature.
- Send via USPS Certified Mail with Return Receipt, plus fax, plus member portal upload.
1. DME wheelchair denial (medical necessity)
Power wheelchair denied as 'not medically necessary' for a patient with progressive neuromuscular disease. Appeal cites Medicare-equivalent medical-necessity criteria, treating physiatrist's evaluation, and functional-status documentation.
Statutes referenced: 29 USC § 1133 · 29 CFR § 2560.503-1 · Medicare LCD L33788 (DME)
[YOUR NAME]
[ADDRESS]
[CITY, STATE ZIP]
[PHONE] | [EMAIL]
Member ID: [MEMBER ID]
[DATE]
Appeals Department
[INSURER NAME]
[INSURER APPEALS ADDRESS]
Re: Internal Appeal of Denial - Power Wheelchair (HCPCS K0856)
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID] | Group: [GROUP NUMBER]
Denial Reference: [REF NO.] | Denial Date: [DATE]
Date of Service Requested: [DATE]
Dear Appeals Reviewer:
This is a formal first-level appeal under 29 USC § 1133 and 29
CFR § 2560.503-1 of the [DATE] denial of pre-authorization for
HCPCS K0856 (Group 3 power wheelchair, single power option) for
[PATIENT NAME]. The denial - stating the device is "not medically
necessary" - is contrary to the medical record, applicable
clinical criteria, and the plan's own coverage policy.
CLINICAL FACTS
[PATIENT NAME] is a [AGE]-year-old [SEX] with [DIAGNOSIS, ICD-10
G12.21 amyotrophic lateral sclerosis / G35 multiple sclerosis /
M62.84 sarcopenia, etc.]. Functional status:
- Ambulation: cannot ambulate more than [DISTANCE] without
assistance and rest.
- Manual wheelchair trial: completed [DATE], unable to
self-propel due to [REASON: upper-extremity weakness, MMT
grade 3/5 bilateral biceps and triceps].
- Activities of daily living: unable to perform mobility-
related ADLs in the home including transfers to and from
[TOILET / KITCHEN / BED] without a power mobility device.
The treating physiatrist (letter attached as Exhibit A) has
performed the in-person mobility evaluation required by
Medicare LCD L33788, which is the de facto industry standard.
The patient meets all general coverage criteria for power
mobility devices: a mobility limitation, no resolution by
cane/walker, inability to safely use manual wheelchair, ability
to safely operate the power device, and home accessibility for
the device.
PLAN POLICY
[INSURER]'s published Medical Coverage Policy [POLICY NUMBER]
on Power Mobility Devices defines coverage criteria as: [QUOTE
PLAN POLICY VERBATIM]. Each criterion is satisfied as detailed
in Exhibit A.
REQUESTED RELIEF
I respectfully request that [INSURER] reverse the [DATE] denial
and authorize HCPCS K0856 with the cushion and accessories
specified in the prescription. Please respond within the
30-day pre-service appeal window required by 29 CFR §
2560.503-1(i)(2)(ii).
Exhibits attached: (A) Treating physiatrist letter and mobility
evaluation, (B) prior treatment summary, (C) home assessment.
Sincerely,
[YOUR SIGNATURE]
[YOUR PRINTED NAME]
2. Mental health therapy session cap (MHPAEA)
Plan limits outpatient psychotherapy to 20 sessions per year while imposing no analogous cap on physical therapy or chiropractic. Appeal frames as a quantitative-treatment-limitation parity violation under MHPAEA.
Statutes referenced: 29 USC § 1185a · 29 CFR § 2590.712 · 29 USC § 1133
[YOUR NAME]
[ADDRESS]
[CITY, STATE ZIP]
[PHONE] | [EMAIL]
[DATE]
Appeals Department
[INSURER NAME]
Re: Internal Appeal - Denial of Psychotherapy Sessions Beyond
Annual Cap | MHPAEA Parity Violation
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID] | Group: [GROUP NUMBER]
Denial Reference: [REF NO.] | Date of Denial: [DATE]
Service Denied: CPT 90837 (psychotherapy, 60 min) on [DATE]
Dear Appeals Reviewer:
This is a formal appeal under 29 USC § 1133 of the [DATE] denial
of CPT 90837 on the ground that [PATIENT] has exceeded the
plan's "20 outpatient mental health visits per year" cap. The
denial violates the Mental Health Parity and Addiction Equity
Act (MHPAEA) at 29 USC § 1185a and 29 CFR § 2590.712 because
the plan does not apply an analogous quantitative treatment
limitation to comparable medical/surgical (M/S) benefits.
CLINICAL FACTS
[PATIENT] is a [AGE]-year-old [SEX] with a primary diagnosis
of [DSM-5 DIAGNOSIS, ICD-10 CODE]. The patient has been
receiving evidence-based psychotherapy from [PROVIDER NAME], a
licensed [PSYCHOLOGIST/CLINICAL SOCIAL WORKER/PSYCHIATRIST],
for [DURATION]. Continued therapy is medically necessary to
prevent [SPECIFIC RISK: relapse, hospitalization, suicidality,
functional decline].
PARITY VIOLATION
29 CFR § 2590.712(c)(2) prohibits a group health plan from
imposing a quantitative treatment limitation on mental health
benefits in any classification unless that limitation applies
to substantially all (at least two-thirds of) M/S benefits in
the same classification, and then only at the predominant
level.
The plan's evidence of coverage shows:
- Outpatient mental health: capped at 20 visits per year.
- Outpatient physical therapy: NO visit cap (medical
necessity governs).
- Outpatient chiropractic: NO visit cap.
- Outpatient occupational therapy: NO visit cap.
- Outpatient office visits to specialty physicians: NO cap.
The 20-visit cap on outpatient mental health is therefore a
QTL imposed on MH benefits without any comparable QTL on
substantially all M/S benefits in the outpatient
classification. This is a facial parity violation.
REQUEST FOR COMPARATIVE ANALYSIS
Pursuant to 29 USC § 1185a(a)(8), I hereby request the plan's
written comparative analysis of the design and application of
this non-quantitative and quantitative treatment limitation.
REQUESTED RELIEF
Reverse the denial, authorize ongoing psychotherapy as
medically necessary, and remove the 20-visit annual cap
prospectively as a violation of MHPAEA.
If denied, I intend to file a complaint with the U.S.
Department of Labor EBSA and the state insurance commissioner
and to request expedited external review under 45 CFR §
147.136.
Sincerely,
[SIGNATURE / PRINTED NAME]
3. Prior auth for urgent surgery (expedited)
Pre-authorization denied for urgent cholecystectomy with biliary obstruction. Appeal demands 72-hour expedited review under 45 CFR § 147.136 with treating surgeon's urgency attestation.
Statutes referenced: 45 CFR § 147.136(a)(2)(iii) · 45 CFR § 147.136(b)(2)(ii)(B) · 29 CFR § 2560.503-1(m)(1)
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
URGENT - 72-HOUR EXPEDITED APPEAL
Appeals Department
[INSURER NAME]
Fax: [APPEALS FAX]
Re: URGENT Expedited Appeal Under 45 CFR § 147.136 and 29 CFR §
2560.503-1(m)(1)
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID]
Denied Service: CPT 47562 (laparoscopic cholecystectomy)
Denial Reference: [REF NO.] | Date of Denial: [DATE]
Dear Medical Director:
This is a request for expedited 72-hour appeal under 45 CFR §
147.136(b)(2)(ii)(B) and 29 CFR § 2560.503-1(i)(2)(i) of the
[DATE] denial of pre-authorization for laparoscopic
cholecystectomy.
URGENCY ATTESTATION
Attached as Exhibit A is a signed attestation from [TREATING
SURGEON], MD, FACS, stating that applying the standard 30-day
pre-service appeal timeframe to this denial would seriously
jeopardize the patient's life or health and would subject the
patient to severe pain that cannot be adequately managed
without the requested surgery. Per 45 CFR § 147.136(a)(2)(iii)
and 29 CFR § 2560.503-1(m)(1), this claim must be treated as
involving urgent care and decided within 72 hours.
CLINICAL FACTS
[PATIENT NAME] presented to [HOSPITAL] on [DATE] with right
upper quadrant pain, nausea, jaundice, and abnormal liver
enzymes (AST [VALUE], ALT [VALUE], total bilirubin [VALUE]).
Imaging:
- Ultrasound [DATE]: cholelithiasis with gallbladder wall
thickening [VALUE] mm.
- MRCP [DATE]: choledocholithiasis with [DEGREE] of biliary
duct dilation.
Diagnosis: acute cholecystitis with choledocholithiasis (ICD-10
K80.62). Standard of care per [SAGES guidelines / ACS
guidelines] is laparoscopic cholecystectomy within 72 hours of
diagnosis.
PLAN POLICY
[INSURER]'s coverage policy [NUMBER] for cholecystectomy lists
this presentation as a covered indication. The denial reasoning
(insufficient documentation of medical necessity) is contrary to
the imaging findings and the surgical evaluation in the medical
record.
REQUESTED RELIEF
(1) Treat this appeal as urgent under 45 CFR § 147.136 and
decide within 72 hours.
(2) Reverse the denial and authorize CPT 47562 immediately.
(3) Confirm authorization in writing by fax within 24 hours.
I am also requesting concurrent expedited external review under
45 CFR § 147.136(d)(1)(ii)(B). Failure to comply with the 72-
hour deadline triggers deemed exhaustion under 29 CFR §
2560.503-1(l).
Submitted by certified mail, fax, and member portal upload.
Sincerely,
[SIGNATURE / PRINTED NAME]
4. Out-of-network ER visit (No Surprises Act)
Plan paid emergency-department claim at out-of-network rates and balance-billed the patient. Appeal asserts No Surprises Act protections at 42 USC § 300gg-111 and applicable state prudent-layperson statute.
Statutes referenced: 42 USC § 300gg-111 · 45 CFR § 149.110 · State prudent-layperson statute
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
Appeals Department
[INSURER NAME]
Re: Appeal - Improper Out-of-Network Cost-Sharing on Emergency
Services (No Surprises Act)
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID]
Date of Service: [DATE OF ER VISIT]
Provider: [HOSPITAL / EMERGENCY PHYSICIAN GROUP]
Claim Number: [CLAIM NO.]
Dear Appeals Reviewer:
This is a formal appeal of the EOB dated [DATE], which applied
out-of-network cost-sharing to an emergency-department visit at
[HOSPITAL] on [DATE], and of any balance billing now being
pursued by the facility or the emergency physician group. The
processing violates the No Surprises Act (NSA) at 42 USC §
300gg-111, implementing regulations at 45 CFR § 149.110, and
the [STATE] prudent layperson emergency-services statute.
FACTS
On [DATE OF SERVICE] at [TIME], [PATIENT NAME] presented to
[HOSPITAL] emergency department with [SYMPTOMS: chest pain,
shortness of breath, severe abdominal pain, etc.]. The patient
believed in good faith that the symptoms required immediate
medical attention to avoid serious health consequences. The
patient received [TREATMENTS, e.g., EKG, troponin, CT
abdomen/pelvis, IV fluids] and was discharged with a final
diagnosis of [DIAGNOSIS, ICD-10].
Per the EOB dated [DATE], [INSURER] processed the claim at
out-of-network rates with patient cost-sharing of $[AMOUNT].
The hospital's bill to the patient totals $[AMOUNT].
LEGAL VIOLATION
42 USC § 300gg-111(a)(1)(C) requires that for emergency
services furnished by a non-participating provider or facility,
cost-sharing must be calculated as if the services were
furnished by a participating provider, and any
cost-sharing applied to the participant must count toward the
participant's in-network deductible and out-of-pocket maximum.
45 CFR § 149.110(c) implements this requirement.
[STATE] law - [INSURANCE CODE §] - separately codifies the
prudent layperson standard, requiring that emergency services
be covered when a prudent layperson with average knowledge of
medicine and health would reasonably expect the absence of
immediate medical attention to result in serious jeopardy. The
patient's presenting symptoms meet that standard.
REQUESTED RELIEF
(1) Reprocess the claim at in-network cost-sharing per 42 USC
§ 300gg-111(a)(1)(C).
(2) Apply patient cost-sharing to the in-network deductible
and out-of-pocket maximum.
(3) Notify the facility and emergency physician group that the
NSA prohibits balance billing and that any balance billing must
be reversed.
(4) Provide written confirmation of compliance within 30 days.
If unresolved, I will file with the No Surprises Help Desk at
1-800-985-3059, the state insurance commissioner, and CMS.
Sincerely,
[SIGNATURE / PRINTED NAME]
5. Specialty drug step therapy override
Specialty biologic denied because patient has not failed plan-required step-therapy preferred agents. Appeal seeks step-therapy override based on contraindication, prior failure outside the plan, and applicable state step-therapy statute.
Statutes referenced: 29 USC § 1133 · State step-therapy override statute · AAAAI / ACR / AGA specialty guideline (as applicable)
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
Pharmacy Appeals
[INSURER / PBM NAME]
Re: Step Therapy Override - Specialty Drug Coverage
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID] | Rx Group: [GROUP]
Denied Drug: [DRUG NAME, NDC, J-CODE]
Denial Reference: [REF NO.] | Date: [DATE]
Dear Pharmacy Appeals Reviewer:
This is a formal appeal of the [DATE] denial of [DRUG NAME] on
the ground that [PATIENT] has not yet failed the plan's
preferred step-therapy agents. I request a step-therapy
override under 29 USC § 1133 (ERISA), [STATE] step-therapy
override law [STATE INSURANCE CODE §], and the plan's own
override criteria.
CLINICAL FACTS
[PATIENT] is a [AGE]-year-old [SEX] with [DIAGNOSIS, ICD-10].
The treating [SPECIALTY] prescribed [DRUG NAME] on [DATE]
because:
- Prior trial of [PREFERRED AGENT 1] from [DATE] to [DATE]:
[OUTCOME - failure, intolerance, contraindication].
- Prior trial of [PREFERRED AGENT 2] from [DATE] to [DATE]:
[OUTCOME].
- [Additional prior trials with documentation].
- Documented contraindication to [PREFERRED AGENT 3]:
[REASON, e.g., hepatic impairment, prior anaphylaxis,
pregnancy].
STEP THERAPY OVERRIDE CRITERIA
The plan's own published step-therapy override policy [POLICY
NUMBER] permits override when the patient (a) has previously
failed the preferred agent, (b) has a documented
contraindication, (c) is currently stable on the requested
drug, or (d) is expected to be ineffective on the preferred
agent based on clinical characteristics. [PATIENT] satisfies
[A AND B / C / D].
[STATE] law at [STATE INSURANCE CODE §] (the [STATE] Step
Therapy Override Act) requires plans to grant overrides under
similar circumstances and to decide override requests within
[STATE TIMEFRAME, e.g., 72 hours for urgent / 5 days for
non-urgent].
GUIDELINE SUPPORT
- [SPECIALTY SOCIETY] [YEAR] guideline for [CONDITION]
recommends [DRUG NAME] in patients meeting the clinical
criteria above.
- [CITATION, PMID]: clinical trial data supporting use in
this patient profile.
REQUESTED RELIEF
(1) Grant step-therapy override and authorize coverage of
[DRUG NAME] effective immediately.
(2) Issue authorization for the prescribed dose, frequency,
and duration through [DATE].
If denied, I will request expedited external review under 45
CFR § 147.136 and file with the state insurance commissioner.
Sincerely,
[SIGNATURE / PRINTED NAME]
6. IVF coverage in state-mandate states
Plan denied IVF cycle as 'experimental/not covered' in a state with an infertility coverage mandate. Appeal cites the state insurance code mandate and supporting clinical workup.
Statutes referenced: State infertility mandate (varies; e.g., NY Insurance Law § 3221(k)(6); IL 215 ILCS 5/356m; MA M.G.L. ch. 175 § 47H) · 29 USC § 1133
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
Appeals Department
[INSURER NAME]
Re: Appeal of IVF Denial - State Infertility Mandate
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID] | Group: [GROUP NUMBER]
Denied Service: IVF cycle, CPT 58970/58974/58976/89253
Denial Reference: [REF NO.] | Date of Denial: [DATE]
Dear Appeals Reviewer:
This is a formal appeal of the [DATE] denial of an IVF cycle on
the ground that the service is "not a covered benefit." The
denial violates the [STATE] infertility coverage mandate at
[STATE INSURANCE CODE §], which requires fully insured group
health policies issued in [STATE] to cover diagnosis and
treatment of infertility, including IVF, subject to the
clinical criteria specified in the statute.
CLINICAL FACTS
[PATIENT] is a [AGE]-year-old [SEX] who has been attempting to
conceive for [DURATION]. The treating reproductive endocrinologist
has completed the workup required by the statute:
- [DURATION] of unprotected intercourse without conception.
- Diagnostic workup including [HSG, semen analysis, AMH, FSH,
LH, TSH, prolactin, antral follicle count, etc.] documented
on [DATES].
- Diagnosis: [PRIMARY/SECONDARY INFERTILITY / DIMINISHED
OVARIAN RESERVE / TUBAL FACTOR / MALE FACTOR / UNEXPLAINED
INFERTILITY], ICD-10 [CODE].
- Prior treatments tried: [OVULATION INDUCTION / IUI cycles
with outcomes].
- Per ASRM 2024 guidance and the treating REI's evaluation,
IVF is the appropriate next step.
STATUTORY ENTITLEMENT
[STATE] law at [STATE INSURANCE CODE §] requires coverage of
IVF when:
- The patient has been unable to conceive for [STATUTORY
DURATION] (or such other criteria as the statute specifies).
- The patient has tried less expensive infertility treatments
that are covered by the policy without success.
- IVF is performed at a facility that conforms to ACOG/SART
guidelines.
[PATIENT] meets each criterion.
PLAN POLICY
The [INSURER] plan was issued in [STATE] on [DATE]. The
infertility mandate applies. The plan cannot exclude
mandate-required services and characterize them as
"experimental" or "not covered."
REQUESTED RELIEF
(1) Reverse the denial.
(2) Authorize the requested IVF cycle including
controlled ovarian hyperstimulation, monitoring, retrieval
(CPT 58970), embryo transfer (CPT 58974/58976), and embryo
cryopreservation (CPT 89258) as appropriate.
(3) Confirm the [STATUTORY MAXIMUM] cycle entitlement under
[STATE INSURANCE CODE §].
If denied, I will file with the [STATE] Department of Insurance
and request external review.
Sincerely,
[SIGNATURE / PRINTED NAME]
7. Pediatric ABA therapy hour cap
Plan denied requested ABA hours for a child with autism, capping at 10 hours per week despite a treating BCBA recommendation of 25 hours. Appeal cites state autism mandate and MHPAEA parity.
Statutes referenced: State autism mandate (varies; e.g., CA Health & Safety Code § 1374.73; NY Insurance Law § 3216(i)(25); TX Insurance Code § 1355.015) · 29 USC § 1185a (MHPAEA) · 29 USC § 1133
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
Appeals Department
[INSURER NAME]
Re: Appeal - ABA Therapy Hours Reduced Below Treating BCBA
Recommendation
Patient: [CHILD'S NAME], DOB [DOB]
Member ID: [MEMBER ID] | Group: [GROUP NUMBER]
Diagnosis: Autism Spectrum Disorder, ICD-10 F84.0
Denied Service: Applied Behavior Analysis, CPT 97153/97155
Denial Reference: [REF NO.] | Date: [DATE]
Dear Appeals Reviewer:
This is a formal appeal of the [DATE] decision authorizing only
10 hours per week of ABA therapy for [CHILD'S NAME] when the
treating Board Certified Behavior Analyst (BCBA) has prescribed
25 hours per week based on a comprehensive assessment. The
denial violates the [STATE] autism coverage mandate at [STATE
INSURANCE CODE §], the Mental Health Parity and Addiction
Equity Act at 29 USC § 1185a, and ERISA's full-and-fair-review
requirement at 29 USC § 1133.
CLINICAL FACTS
[CHILD'S NAME], age [AGE], was diagnosed with Autism Spectrum
Disorder by [DIAGNOSING PSYCHOLOGIST/DEVELOPMENTAL PEDIATRICIAN]
on [DATE], confirmed by ADOS-2 and ADI-R. Functional baseline:
- Communication: [DETAIL - nonverbal, limited verbal,
pragmatic deficits].
- Adaptive: Vineland-3 ABC standard score [VALUE].
- Maladaptive behaviors: [SELF-INJURIOUS, AGGRESSION,
ELOPEMENT, etc.] occurring [FREQUENCY].
The treating BCBA's comprehensive assessment dated [DATE]
(attached as Exhibit A) recommends 25 hours per week of
focused/comprehensive ABA based on the Council of Autism
Service Providers (CASP) Practice Guidelines and the BACB
Professional and Ethical Compliance Code.
STATE MANDATE
[STATE] law at [STATE INSURANCE CODE §] requires fully
insured group health policies to cover the diagnosis and
treatment of autism spectrum disorder, including ABA, without
arbitrary hour or dollar caps that conflict with the treating
provider's recommendation. [Plan must specify any statutory
language limiting hours.]
MHPAEA PARITY
29 USC § 1185a and 29 CFR § 2590.712 prohibit imposing on
behavioral health benefits any treatment limitation that is
more restrictive than the predominant limitation applied to
substantially all comparable medical/surgical benefits. The
plan does not cap hours of physical therapy, occupational
therapy, or speech therapy when ordered by the treating
provider for a developmental disability. The 10-hour ABA cap
is therefore a parity violation. Pursuant to 29 USC §
1185a(a)(8), I request the plan's written comparative
analysis of any non-quantitative treatment limitation applied
to ABA services.
REQUESTED RELIEF
(1) Authorize 25 hours per week of ABA as recommended by the
treating BCBA, through the next clinical reauthorization date.
(2) Cease applying the 10-hour cap.
(3) Produce the MHPAEA comparative analysis.
If denied, I will file complaints with the U.S. Department of
Labor EBSA, the [STATE] Department of Insurance, and request
external review under 45 CFR § 147.136.
Sincerely,
[PARENT/GUARDIAN SIGNATURE]
[PRINTED NAME]
8. Bariatric surgery pre-op requirements
Plan denied bariatric surgery on the ground the patient has not completed a six-month medically supervised weight-loss program. Appeal cites updated ASMBS/ACS guidelines and the plan's own coverage criteria.
Statutes referenced: 29 USC § 1133 · 29 CFR § 2560.503-1 · ASMBS/ACS 2022 Indications Update
[YOUR NAME]
[ADDRESS]
[PHONE] | [EMAIL]
[DATE]
Appeals Department
[INSURER NAME]
Re: Internal Appeal - Bariatric Surgery Denial
Patient: [PATIENT NAME], DOB [DOB]
Member ID: [MEMBER ID] | Group: [GROUP NUMBER]
Denied Service: CPT 43644 (laparoscopic Roux-en-Y gastric
bypass) / 43775 (sleeve gastrectomy)
Denial Reference: [REF NO.] | Date of Denial: [DATE]
Dear Appeals Reviewer:
This is a formal appeal under 29 USC § 1133 and 29 CFR §
2560.503-1 of the [DATE] denial of pre-authorization for
bariatric surgery on the ground that [PATIENT NAME] has not
completed a six-month medically supervised weight loss program.
The denial is contrary to the current ASMBS/IFSO 2022
Indications for Metabolic and Bariatric Surgery, the plan's
own coverage policy, and the medical record.
CLINICAL FACTS
[PATIENT] is a [AGE]-year-old [SEX] with:
- BMI [VALUE] kg/m^2 documented on [DATE] (Class III obesity,
ICD-10 E66.01).
- Comorbidities: [TYPE 2 DIABETES, OBSTRUCTIVE SLEEP APNEA,
HYPERTENSION, HYPERLIPIDEMIA, NAFLD, GERD - list with
diagnosis dates and current control].
- Documented prior weight-loss attempts: [DETAIL with dates,
interventions, outcomes].
- Comprehensive multidisciplinary evaluation completed:
bariatric surgeon ([DATE]), bariatric dietitian ([DATE]),
psychological evaluation ([DATE], cleared for surgery).
CURRENT GUIDELINES
The 2022 ASMBS/IFSO joint statement (Eisenberg et al., Surg
Obes Relat Dis 2022; PMID: 36280539) explicitly states that
"there is no high-quality evidence" that mandatory preoperative
weight-loss programs improve outcomes, and recommends against
imposing such requirements as a barrier to access. The American
College of Surgeons MBSAQIP standards similarly do not require
a six-month program.
PLAN POLICY
[INSURER]'s coverage policy [POLICY NUMBER] requires (a) BMI
>= 40, or BMI >= 35 with one comorbidity; (b) documented
participation in a medically supervised weight-management
program; (c) psychological clearance; (d) nutritional
counseling. The patient meets criteria (a), (c), and (d). For
criterion (b), the patient has documented participation in
[DETAIL - structured weight-management program, medical visits
with weight tracking, nutrition counseling] over [DURATION].
The plan's policy does not specify a six-month minimum
duration; the denial improperly grafts a duration requirement
that is not in the policy and is contrary to current evidence.
REQUESTED RELIEF
(1) Reverse the denial.
(2) Authorize CPT [43644 / 43775] effective [DATE] at
[FACILITY].
(3) Confirm authorization in writing within the 30-day
pre-service appeal window required by 29 CFR § 2560.503-1(i).
I am requesting same-specialty review by a bariatric surgeon
under 29 CFR § 2560.503-1(h)(3)(iii). The treating surgeon is
available for peer-to-peer discussion at [PHONE].
Sincerely,
[SIGNATURE / PRINTED NAME]
Exhibits: (A) Bariatric surgeon's letter and operative
indication, (B) comorbidity documentation, (C) weight-management
participation log, (D) psychological evaluation, (E) ASMBS/IFSO
2022 statement.
Pairing the letter with regulator complaints
A strong appeal letter on its own moves some denials. A letter paired with simultaneous filings with the right regulators moves more. After mailing the appeal, consider:
- State insurance commissioner for fully insured plans. See our commissioner complaint guide.
- U.S. Department of Labor EBSA at 1-866-444-3272 for ERISA self-funded plans.
- CMS CCIIO for marketplace and individual plans.
- External review under 45 CFR § 147.136 after internal appeals exhaust. See our external review guide.
Frequently asked questions
Are these letters real or templates?
These are templates - composites drafted by Counterclaim from publicly available appeals patterns and statutory citations. They contain placeholders like [PATIENT NAME] that you must replace with your actual facts. They are not from real patient cases and do not contain real PHI.
Can I just copy and send one of these?
No. Each template must be customized with your specific facts, dates, denial reference numbers, ICD-10 codes, CPT codes, plan name, member ID, treating physician's name, and the actual statutory citations applicable to your state and plan type. A facially generic appeal will not move an insurer.
What documents do I attach to the appeal?
At minimum: the original denial letter or EOB, your treating physician's letter of medical necessity, all supporting medical records (office notes, imaging, labs), the plan's published medical-coverage policy for the service, and any peer-reviewed literature you cite. For state-mandate appeals (autism, IVF, mental health), include a copy of the state statute.
How do I send the appeal?
USPS Certified Mail with Return Receipt to the appeals address listed on the denial letter, plus fax and member portal upload if available. Multiple channels prevent the insurer from claiming non-receipt and start the regulatory clock with provable delivery.
Is this legal advice?
No. These templates are informational drafting aids. Counterclaim is not a law firm and does not provide legal advice. If your case involves more than $25,000 in disputed coverage, an active mental health crisis, or complex specialty care (oncology, transplant), consult a licensed attorney - many ERISA plaintiff attorneys take cases on contingency under 29 USC § 1132(g).
How does the AI generator differ from these templates?
The Counterclaim home-page generator analyzes your specific denial letter, identifies the controlling statutes for your state and plan type, and produces a fully populated, adversary-tested appeal with the correct citations and exhibit list. The templates here are static; the generator adapts to your case.
Can a state insurance commissioner file the appeal for me?
No. Commissioners investigate complaints and pressure insurers, but you (or your attorney) must file the actual internal appeal. See our complaint guide for the regulator's role.
Where can I find more sample letters by scenario?
The Patient Advocate Foundation, Triage Cancer, NAMI, the Autism Society, and many state attorney general offices publish sample appeal letters. Each varies in quality. Use them as supplementary references; the templates here are designed to be regulator-compliant out of the box.
See also: ERISA appeals, expedited 72-hour appeal, mental health parity, external review and IRO, letter of medical necessity, peer-to-peer review, and insurance commissioner complaint.