Previous Excerpt 10 “Table of Contents — Frontal Attack”

If the rest of your appeal document were lost, the entire case would be found in your cover letter.

Purpose

The cover letter has three jobs:

  • Introduce you and your case
  • Present your arguments
  • Tell them to approve your treatment.

Stay on point. The cover letter is not to tell all of the injustices that have happened, or to right all the wrongs that have occurred since you started tangling with the insurance company.

Complaining about the insurance company is self-indulgent and ineffective. It doesn’t add to your case, and it doesn’t belong in an appeal.

You are simply laying out the groundwork for your case. Read my sample letter for tone—cool, commanding, professional.

Writing an appeal is the same as teaching a class. First, tell them what you are going to do. Second, do it. Third, remind them of what you did.

You are teaching the insurance company how to pay for your treatment.

 

————————————————————-

John Q. Patient
123 Maple Street
Anytown, CO 01234

January 1, 2011

Member Service Specialist
Acme Insurance of Colorado
P.O. Box 100
1000 First Avenue
Denver, CO 80230
EXPEDITED APPEAL REQUEST

 

Dear Sir or Madam –

 

I am a 58-year-old man who has been diagnosed with appendix cancer
(adenomucinosis type). My local Acme and Acme-contracted physicians have only palliative care to offer for my disease.

There is one treatment that offers a proven, scientifically documented      chance of a good outcome for appendix cancer. This combined modality treatment involves a radical, meticulous, painstaking removal of all tumor nodules exceeding 2.5 mm. In order for this level of tumor removal to be achieved, a number of complex surgical procedures—including peritonectomy procedures—must be performed.

I have requested this treatment, and Acme has denied it, for the following reasons:

  1. I do not have an out-of-network benefit.
  2. The cytoreductive surgery and HIPEC (heated intraperitoneal chemotherapy) are experimental/investigational.

There is no Acme or Acme-contracted surgeon who is qualified to perform cytoreductive surgery. During my debulking surgery of 6/14/09, the procedures necessary to achieve complete cytoreduction were not performed.
Dr. Hart left large volume residual tumor—a guarantee of recurrence.

Further, there is no Acme physician who is experienced in performing the heated intraperitoneal chemotherapy (HIPEC) that is a critical part of this combined treatment. HIPEC is not just “one more chemotherapy.” It is not chemotherapy at all. It is part of a surgical treatment that has been proven over twenty-five years to yield exponentially better outcomes than palliative debulking surgeries and systemic chemotherapy.

Dr. Sugarbaker has performed over 1500 cytoreductive surgeries, the majority of them for disseminated appendix cancer. He has kept exhaustive statistics, as he continuously evaluates and improves his criteria for patient selection and treatment regimens. He has published 452 peer-reviewed medical journal articles, documenting in detail the surgical procedures that he has developed, the rationale and methods of delivering the HIPEC, diagnostic and prognostic features of the various types of appendix cancer. And, over the years, he has thoroughly documented his outcomes, survival rates, and rates of recurrence.

Dr. Sugarbaker began performing cytoreductive surgeries for disseminated
abdominal cancers in 1979. Over the years, his combined modality treatment has become standard of care—both in the United States, and around the world. Consquently, I am able to offer abundant scientific proof and professional consensus of the efficacy and safety of this treatment for appendix cancer.

Acme has recognized this by funding out-of-network treatment with Dr.Sugarbaker a number of times.

In this document, I will prove the following facts:

  • Local Acme doctors offer only palliative treatments for my disease.
  • Local Acme-contracted surgeons are not equipped or qualified to perform this treatment. There is abundant clinical evidence that this treatment offers a statistically significant, well-documented clinical benefit for patients with appendix cancer.
  • HIPEC is a critical part of this combined modality treatment.
  • Dr. Paul Sugarbaker is the world-renowned expert in appendix cancer, with vast experience, impeccable credentials, and documented good outcomes with this rare cancer. Acme participating surgeon Dr. Tom Wilson recognized this.
  • This treatment is not experimental, per Acme’s own definition.
  • Medical Necessity: Cytoreductive surgery and HIPEC meets the standard of medical necessity per Acme’s own definition.
  • Acme Insurance of Colorado has paid for this treatment four times in the past year.
  • All of the major insurers—including Blue Cross and Blue Shield, BC/BS Regence, BC/BS Healthwise Plan of WA, United Healthcare, Aetna, and Cigna—routinely pay for cytoreductive surgery and HIPEC for appendix cancer with non-participating, out-of-area providers.
  • Acme first-level review violates Colorado Revised Statute 10-16-113, (3) (a) (V).
  • First-level review offers spurious “proof.

I appreciate your time and attention to a careful review of my urgent expedited appeal. I believe that it sheds light on the true clinical situation which should be at issue here. I am sure that you will come to the same conclusion that so many decision-makers at Acme have come to before: Effective treatment for this cancer is provided for in my contract, but effective treatment is not currently available within Acme Insurance of Colorado.

An out-of-network treatment referral is expected promptly, as further delay will only serve to reduce my chances for a good outcome.
Sincerely,

John Q. Patient

————————————————————-

Introduce yourself and your case

Page one of the cover letter neatly summarizes the situation that has brought you to this appeal.

1. In the first sentence, introduce yourself and your disease. In sentence two, explain why your current treatment is unacceptable:

I am a 58-year-old man who has been diagnosed with appendix cancer (adenomucinosis type).My local Acme and Acme-contracted physicians have only palliative care to offer for my disease.

2. Introduce your requested treatment, begin to teach them about it:

There is one treatment that offers a proven, scientifically documented chance of a good outcome for appendix cancer. This combined modality treatment involves a radical, meticulous, painstaking removal of all tumor nodules exceeding 2.5 mm. In order for this level of tumor removal to be achieved, a number of complex surgical procedures—including peritonectomy procedures—must be performed.

3. State the reason for the denial:

I have requested this treatment, and Acme has denied it, for the following reasons:

  1. I do not have an out-of-network benefit.
  2. The cytoreductive surgery and HIPEC (heated intraperitoneal chemotherapy) are experimental/investigational.

4. Explain why you can’t get the treatment in network:

There is no Acme or Acme-contracted surgeon who is qualified to perform cytoreductive surgery. During my debulking surgery of 6/14/09, the procedures necessary to achieve complete cytoreduction were not performed. Dr. Hart left large volume residual tumor—a guarantee of recurrence.

Further, there is no Acme physician who is experienced in performing the heated intraperitoneal chemotherapy (HIPEC) that is a critical part of this combined treatment. HIPEC is not just “one more chemotherapy.” It is not chemotherapy at all. It is part of a surgical treatment that has been proven over twenty-five years to yield exponentially better outcomes than palliative debulking surgeries and systemic chemotherapy.

5. Introduce your out-of-network expert:

Dr. Sugarbaker has performed over 1500 cytoreductive surgeries, the majority of them for disseminated appendix cancer. He has kept exhaustive statistics, as he continuously evaluates and improves his criteria for patient selection and treatment regimens. He has published 452 peer-reviewed medical journal articles, documenting in detail the surgical procedures that he has developed, the rationale and methods of delivering the HIPEC, diagnostic and prognostic features of the various types of appendix cancer. And, over the years, he has thoroughly documented his outcomes, survival rates, and rates of recurrence.

Dr. Sugarbaker began performing cytoreductive surgeries for disseminated abdominal cancers in 1979. Over the years, his combined modality treatment has become standard of care—both in the United States, and around the world. Consquently, I am able to offer abundant scientific proof and professional consensus of the efficacy and safety of this treatment for appendix cancer.

6. Notify them that you know that they have paid before:

Acme has recognized this by funding out-of-network treatment with Dr. Sugarbaker a number of times.

7. Present your arguments (Bullet Points):

  • Local Acme doctors offer only palliative treatments for my disease.
  • Local Acme-contracted surgeons are not equipped or qualified to perform   this treatment.
  • There is abundant clinical evidence that this treatment offers a statistically significant, well-documented clinical benefit for patients with appendix cancer.
  • HIPEC is a critical part of this combined modality treatment.
  • Dr. Paul Sugarbaker is the world-renowned expert in appendix cancer, with vast experience, impeccable credentials, and documented good outcomes with this rare cancer. Acme participating surgeon Dr. Tom Wilson recognized this.
  • This treatment is not experimental, per Acme’s own definition.
  • Medical Necessity: Cytoreductive surgery and HIPEC meets the standard of medical necessity per Acme’s own definition.
  • Acme Insuarance of Colorado has paid for this treatment four times in the past year.
  • All of the major insurers—including Blue Cross BlueShield, BC/BS Regence, BC/BS Healthwise Plan of WA, United Healthcare, Aetna, and Cigna—routinely pay for cytoreductive surgery and HIPEC for appendix cancer with non-participating , out-of-area providers.
  • Acme first-level review violates Colorado Revised Statute 10-16-113, (3) (a) (V).
  • First-level review offers spurious “proof.”

9. Tell them to approve your treatment (the Call to Action):

I appreciate your time and attention to a careful review of my urgent expedited appeal. I believe that it sheds light on the true clinical situation which should be at issue here. I am sure that you will come to the same conclusion that so many decision-makers at Acme have come to before:

Effective treatment for this cancer is provided for in my contract, but effective treatment is not currently available within Acme Insurance of Colorado.

An out-of-network treatment referral is expected promptly, as further delay will only serve to reduce my chances for a good outcome.

Sincerely,

 

John Q. Patient

By the way, I have stated that I only use one typestyle in a document. This section is the one exception to that rule. In order to set off long quotations, I indent the text, and change to a smaller size (10 pt Arial) to set it off.

The appeal is an exercise in persuasion. And, an exercise in persuasion is also an exercise in teaching.

Don’t assume that any high- or low-level bureaucrat at Acme Insurance knows anything about your requested treatment. They don’t know, and they aren’t going to expend any energy finding out.

Make it easy for them. Lead them where you want them to go.

The cover letter lays out your case, step by step. The purpose of the rest of the appeal is to prove your case with facts.

Next Excerpt 12 “Treatment of Choice — Focus on You Objective”
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