Dear Insurance Company,
_______________ (birthdate _______________; policy number _______________) has been under my care for _______________ condition for _______________ years. I have determined that they will benefit from _______________ surgery, and in fact it is essential to their health and long-term survival that this treatment be granted.
Along with _______________, my patient has the following comorbid conditions: _______________.
Multiple varied attempts to manage or mitigate this condition have been made, and the results were _______________. Moreover, their ability to take further steps are limited due to _______________. Their family medical history indicates _______________.
I request pre-authorization for _______________, to be fully covered. Thank you.
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