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My Car

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Submitted By Bebe1414
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My insurance Company Representative
Name of my insurance
Insurance companies street address
City, State, and the zip code

Re: Request for reconsideration of coverage denial.

Jill Ermer
My insurance name PPO
ID# ABC0000D0000
Bin# 123456

Dear Sir or Madam,

After receiving a bill from Blank Radiology Associates LLC I have decided to appeal your decision to deny coverage of my recommended treatment plans for both my CT Thorax w/dye on June 11th and trans-vaginal ultrasound on June 4th.

In the billing code 10 (per your insurance carrier, theses services were not medically necessary. Payment was denied) was given for cat scan w/dye done on June 11th at Blank Hospital in Buffalo NY in which treatment was ordered by Dr. Jane Doe. Also code 11 (per your insurance carrier these services were for a pre-existing condition. Payment was denied) for my Transvaginal ultra-sound performed on June 4th ordered by Doctor John Doe at Blank Hospital in Buffalo NY.

On June 11th I entered the emergency room at Blank Hospital suffering from severe chest pains and an inability to breathe. Due to the fact that I have been diagnosed with not one, but two blood clotting disorders the risk of having a potentially fatal blood clot in my lung was highly suspected. In order to properly diagnosis if I had a potential deadly blood clot a CT Thorax w/dye was absolutely necessary. I know this because I was not only approached by a specialist but I was also counseled by the hospital administrator and a religious counselor. In which they made it absolutely clear that if I did not have this procedure death was an extremely high risk. If I had a blood clot in my lungs as it would travel to my heart and kill me instantly. To deem this procedure as medically unnecessary is not only an issue of legality but it is a moral issue as well. Basically I view this determination as a lack of compassion as to whether or not a client dies. I hope that this is not common practice because I don't think the State Medical Board nor the Attorney General would agree with it. I don't mean to sound hostile but such a code given is very discerning as it makes me feel as if my life has no value what so ever.

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