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Uses their own policies and medical evidence against them.
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Sources: Kaiser Family Foundation Analysis of ACA Marketplace Data (2022-2023) | Premier, Inc. Healthcare Claims Analysis (2023) | KFF Internal Appeals Success Rate Study (2023)
Your knight in shining armor against insurance denial barriers
Their Denial:
"Not medically necessary"
Our Counter:
"Your own policy #2195 explicitly covers this treatment when criteria X, Y, Z are met - all documented here."
💡 The Magic:
Who We're CCing (12 Recipients):
Impact:
Insurance company knows 12 oversight bodies are watching. They can't ignore you anymore.
They Expect
You to Give Up
We Break Through
Their Barriers
RE: Appeal for Denial of Zepbound (Claim #UHG-2024-789456)
Dear Appeals Committee,
Your denial stating "not medically necessary" directly contradicts FDA approval for my exact condition and your own Medical Policy #2195, Section 4.3.
THE JUJITSU MOVE:
You denied coverage citing "lack of established efficacy." However, the FDA approved tirzepatide specifically for Type 2 diabetes with obesity based on SURMOUNT-1 trials showing 22.5% average weight loss. Your denial contradicts federal regulatory findings.
Furthermore, three similar denials by UnitedHealth were overturned in Florida this year (Cases: FL-2024-1847, FL-2024-2093, FL-2024-2561). The Department of Insurance ruled these denials "arbitrary and capricious."
THE PRESSURE:
This appeal is being sent to 4 strategic decision-makers BY NAME who have the power to reverse your denial. Each recipient can trigger investigations, penalties, and contract reviews.
I require reversal within 72 hours per Florida Statute 627.42393.
Sincerely,
Sarah Johnson
CC: Maximum Leverage Recipients (Names Matter)
These 4 names transform a private denial into a public accountability issue.
Sarah Johnson 456 Oak Street Minneapolis, MN 55401 Phone: (612) 555-0123 Email: sarah.johnson@email.com January 15, 2025 UnitedHealthcare Appeals Department P.O. Box 6106 Cypress, CA 90630-0006 RE: URGENT Appeal for Denied Prior Authorization Patient: Sarah Johnson Date of Birth: 03/15/1978 Member ID: U987654321 Group #: GRP-55401 Claim #: PA2024-789456 Treatment: MRI of Lumbar Spine Provider: Dr. Sarah Mitchell, MD Provider NPI: 1234567890 Facility: Minneapolis Medical Center Dear Appeals Review Committee, I am writing to formally appeal your denial of prior authorization for an MRI of my lumbar spine, dated January 8, 2025. This denial contradicts both medical necessity standards and your own coverage policies. MEDICAL NECESSITY: I have been experiencing severe lower back pain for over 8 weeks, with progressive neurological symptoms including: • Numbness and tingling in both legs • Difficulty walking more than 50 feet • Loss of bladder control incidents (documented 3 times) My physician, Dr. Sarah Mitchell, has documented that conservative treatments have failed: • 8 weeks of physical therapy (16 sessions completed) • NSAIDs and muscle relaxants (inadequate pain relief) • Epidural steroid injection (temporary relief for only 5 days) POLICY CONTRADICTION: Your denial cites "lack of medical necessity," yet your own Medical Policy #0195 (updated 10/2024) clearly states that MRI is indicated when: 1. Conservative treatment has failed for 6+ weeks ✓ 2. Progressive neurological deficits are present ✓ 3. Red flag symptoms suggest serious pathology ✓ All three criteria are met in my case, as documented in the attached medical records. CLINICAL URGENCY: The American College of Radiology Appropriateness Criteria rates MRI as "Usually Appropriate" (score 7-9) for patients with my symptoms. Delaying this diagnostic test risks: • Permanent nerve damage • Cauda equina syndrome • Irreversible loss of function PEER-REVIEWED EVIDENCE: The Journal of the American Medical Association (2023) confirms that early MRI for patients with progressive neurological symptoms reduces long-term disability by 47% and healthcare costs by $12,000 per patient. REQUEST FOR IMMEDIATE ACTION: Given the urgent nature of my symptoms and clear medical necessity, I respectfully request: 1. Immediate reversal of your denial 2. Expedited authorization for the MRI 3. Written confirmation within 72 hours per state regulations I have been a loyal member for 12 years and have never filed an appeal. This treatment is not elective—it is essential for preventing permanent disability. Please contact Dr. Mitchell at (555) 123-4567 if you need additional clinical information. I am prepared to pursue external review and all legal remedies if this medically necessary care continues to be denied. Thank you for your immediate attention to this urgent matter. Sincerely, Sarah Johnson (612) 555-0123 sarah.johnson@email.com Enclosures: • Complete medical records (46 pages) • Dr. Mitchell's letter of medical necessity • Physical therapy progress notes • Your Medical Policy #0195 highlighting covered criteria
Result: Appeal Approved in 48 Hours
Zepbound coverage approved. $1,200/month medication now covered.
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Pressure Applied
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