City, State, Zip Code
Re: Tina Smith
Insurance I.D. #
Date of Birth
Dear Jane Doe:
My wife and I would like to take the opportunity to provide additional information and documentation about our daughter’s desperate need to receive inpatient treatment at NAME OF TREATMENT CENTER.
Tina’s life is in serious danger. Her treatment team, composed of an eating disorders specialist, a psychotherapist, and a registered dietitian, agree that Tina immediately requires inpatient treatment at a residential treatment program that specializes in the treatment of adolescents and young adults with eating disorders. Partial Hospitalization has been unsuccessful. Tina refuses to eat anything except an apple and maybe lettuce, and then insists on exercising to burn off the few calories she has taken in. Our lovely, once vibrant 5’2’’ daughter now weighs less than eighty pounds. She has been hospitalized four times in the last six months. Tina is desperately ill and has told us she wants to get better but is caught in the nightmare of her eating disorder. Although she is now medically stable, the treatment team believes it is likely Tina will require medical hospitalization again if she does not get help at NAME OF TREATMENT CENTER.
We were very excited to learn that NAME OF TREATMENT CENTER has an available bed. Although we recognize that it is not in your network, the only facility in your network is not appropriate for Tina because it does not specialize in treating adolescents. Our daughter is only 12 years old and we, along with her treatment team, strongly believe she needs to be at a facility that only treats women under 18. Her therapist also feels strongly that she would not be in a facility that has women in their forties and fifties who have struggled with eating disorders for many years (please see the attached copy of his evaluation). NAME OF TREATMENT CENTER was denied due to being an out-of-network facility. We would like to appeal this denial. We are prepared to seek legal counsel if INSURANCE COMPANY is unwilling to approve the treatment our daughter needs and that both her physician and therapist have recommended. The cost of sending her to NAME OF TREATMENT CENTER will be far less than the cycle of recurrent medical hospitalizations that she is currently stuck in. More importantly, it will put Tina on the path to recovery and give her back her life.
Thank you for the opportunity to appeal. We look forward to hearing from you.
Your Name and Contact Info