Check with your Interventional Radiologist BEFORE starting any insurance appeal process. 

This is a SAMPLE of what N.B. of Michigan Personal Appeal Letter might contain.  It is important that you use your own personal medical data in your ‘Personal Appeal Letter’ (the information was changed for confidentiality purposes).

(date)

Name here OR To Whom It May Concern,

Opening statement containing the ‘reason you decided on the UAE treatment’.

Ø   (Example) I am sending you this letter to explain the reason I decided Uterine Artery Embolization (UAE) was the correct uterine fibroid treatment for my particular medical case.

Doctor consultation information and background on medical tests that were performed to evaluate your medical condition.

Ø  (Example) After my gynecologist consultation I felt that I needed to get a second opinion from another gynecologist.  I chose Dr. (xxx) to do a medical examination and he looked over my medical records concerning my condition.  Dr. (XXX) and I talked about all the uterine fibroid treatment options available (hysterectomy, myomectomy, watchful waiting, medical therapy, and uterine artery embolization).  He explained the procedures and said he felt that I was a good candidate for the UAE procedure.  He strongly recommended a more aggressive fibroid treatment be performed as soon as possible.

Ø  (Example) He referred me to an Interventional Radiologist.  I set up a consultation with the Interventional Radiologist to discuss my medical case.  The doctor checked my records and said I was a good candidate for the UAE procedure.

Information on the timeframe you suffered with uterine fibroid symptoms.

Ø  (Example) I suffered with the following fibroid symptoms for over three years.  Please note, that the symptoms continued to increase in intensity.  By the time I went for my Gyn second opinion and Interventional Radiologist consultations the pain was becoming unbearable and I was using a lot of pain medicine to help me cope with my everyday activities.

List the symptoms in the order of their appearance.

(Example) The symptoms are listed in the order of their appearance.  ALL of the symptoms were present, the last month before my UAE (date). 

Ø  (Example) Bulk feeling all the time (this was due to the fibroids and uterus growing at an alarming rate).  There was pressure under my ribs and it made it difficult for me to do any kind of exercise before the UAE.

Ø  (Example) I used Naproxen, 600 mgs (1 tablet every 6 hours), for two weeks out of every month for painful cramps (approximately 15-20 pills).  The Naproxen wasn’t relieving the pain the last four months before my UAE.

Ø   (Example) Anemia (due to blood loss).  I was always tired.

How did it affect your lifestyle?

(Example) I was always feeling ill.  I couldn’t stand the pain.  The pain medicine wasn’t controlling the spasms (labor-like pains).  My quality-of-life was being affected and I wanted treatment to eliminate this discomfort.

Below are some of the ways the uterine fibroid disease was affecting my lifestyle:

Ø   (Example) I was gaining weight at an alarming rate.  When I went to the doctor I was 25 pounds over weight. 

Ø  (Example) I had to purchase clothes two clothes sizes larger because I could no longer wear my wardrobe.  My abdomen looked like I was five months pregnant.  It was also affecting my posture.  It was causing me to have back pain most of the month.

Closing statement including how you feel since the UAE treatment.

Ø  (Example) I investigated the Interventional Radiologist and the hospital where he performed the procedure.  After checking several doctors and hospitals I then decided on Dr. (XX).  At that time he had performed over 900 UAE procedures with a high success rate.

Ø  (Example) All the needed insurance paperwork was submitted to (insurance company name).  It was confirmed that the procedure would be covered and that I could proceed to schedule the UAE procedure.

Ø  (Example) The UAE procedure was performed on (date).  Many of my uterine fibroid symptoms are decreasing in intensity or completely eliminated.  I had my first period and the bleeding was lighter and the cramps were very mild.  I asked the doctor about my symptoms and he said it might take a few more months to completely get rid of the uterine fibroid symptoms.  I am very pleased with the way I feel physically and I am starting to get back my energy and strength to exercise and do everyday activities again.

Please let me know if you need more information.  I appreciate your cooperation in this matter.

Best Regards,

Your signature

(Contact Information:  name, street address, city, state, daytime phone number, e-mail address, etc.)