Health Symphony Appeal Letter
for Assistant Surgeon Denial
Your name and address
Date
Address of Claims review department
RE: Name of Insured:
Plan ID #:
Claim #:
Dear Claims Review Department:
I have recently received a denial from [health plan name] for services performed by an
assistant surgeon [procedure name and code]. I have enclosed a copy of the original
claim and your denial.
[Name of procedure] is a major surgery and requires the presence of a second surgeon. I
have enclosed additional documentation stating this from third party sources. Based on
this information, most payers allow an assistant surgeon for this surgical procedure.
These health plans include [list the health plans]. My surgeon [name of surgeon] had
determined that a second surgeon was medically necessary to ensure the safety of the
patient.
Please reconsider your denial and properly reimburse for the submitted claim. If you have
any questions, please contact my primary care physician at [phone number] or surgeon at
[phone number].
Sincerely,
[Insured’s name]
Enclosures and Research Required
Copy of Claim
Copy of Explanation of Benefits and/or Denial
List of health plans that allow an assistant surgeon for this procedure
Any additional documentation stating the medical necessity for an assistant
surgeon for this medical procedure