Your Full Name
Your Full Address
Your City, State and Zip
Your Phone Number with Area Code

Current Date
Insurance Provider’s Name
Insurance Provider’s Address
Insurance Provider’s City, State, Zip

Dear Insurance Provider (insert name of insurance provider contact),

In your first paragraph, mention the following points:

•    State that you are appealing the decision to deny coverage for your surgery. 
•    Explain why you are appealing.  
•    Briefly introduce your personal history with obesity.

In your second paragraph, mention the following points:

•    Provide more in-depth history of your struggle with weight.
•    Mention any previous attempts with weight loss. 
•    If possible, include documentation of diets or weight-loss products you have tried.

In your last paragraph, mention the following points: 

•    List all reasons why your appeal should be considered.
•    Explain any steps you have been taking to meet requirements. 
•    Include any related health issues you may have.
•    Conclude with the impact that having surgery would have on your life. 

Sincerely,
Your Full Name

Learn more about the insurance appeal process.

This content is adapted from The OAC (Obesity Action Coalition).