Dear Appeals Analyst,
RE; APPEAL TO DENIED NETWORK-GAP EXCEPTION
My name is ___________________________, I write on the above reference to appeal the
insurer’s decision to deny coverage for my pressing knee surgery under
_____________________________________________ [name of health plan and policy
number].
It is my understanding that the insurer is denying coverage on the basis that the surgery will be
provided out of network. Please note that the need to get an out of network surgeon is a
necessity rather than a choice on my part. My condition requires out of network specialized, and
expeditious action failure to which I may suffer irreversible health and economic consequences
since there are no comparable services offered within the network.
In December 2021, a surgeon in Chicago conducted ACL and meniscus surgery on my right
knee. Unfortunately, I have been unable to recover from the surgery to the extent that my
mobility is hampered.
I have relentlessly but unsuccessfully sought treatment from various in network orthopedic
surgeons. Notably, I consulted with three in-network orthopedic surgeons, including the most
renowned orthopedic surgeon in Pennsylvania and the Head of Orthopedic Surgery at Johns
Hopkins (Baltimore). All three had consenting statements stating that:
My condition named ‘Arthrofibrosis’ is dire, and rare;
They lacked the necessary skills to operate on me or perform the surgery successfully;
and
I should only have a specialist operate on me to treat it.
I have also done online research that revealed that persons with a comparable condition who
used ordinary orthopedic surgeons were forced to visit Arthrofibrosis specialists after 5-7 failed
procedures and serious side effects. Only 10–12 specialist surgeons exist in the US for my
condition, and they are all out-of-network. I personally met with three of these experts in Ohio,
Indiana, and Texas, and I felt confident enough to proceed with the surgery with the Texas-based
specialist who previously worked and conducted research at the famed Steadman Clinic in Vail,
Colorado, and collaborated with Dr. Richard Steadman, who helped to pioneer many innovations
in knee surgery.
Having the procedure performed by a specialist will ensure better recovery and the return of my
knee’s proper function in addition to saving the insurer’s cost of repeat surgeries done by regular
orthopedic surgeons. Moreover, the cost of the out of network provider is comparable to those of
the in-network provider contracted rates.
I humbly request for an expedited hearing, and that I receive response to this request within 72
hours of its receipt due to the urgent nature of my condition. I have attached relevant documents
to support my appeal for your perusal.
Thank you for your immediate attention to this matter.
2
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