The Request for Policy Evaluation is a newer document (these were assembled from a variety of sources). I created the policy evaluation and recommend viewing it first and comparing the format and content to the document below and using what you feel pertains best to your specific case.
The document below is an actual set of appeal letters submitted around 2015. I believe the carrier was Medicare. The case was won. I did not create it but have made some edits for clarity. It is for educational purposes only. Instructions for the following documents.
In Word search for all [brackets] and pay careful attention to [dates] and [Dr. Smith, M.D.].
There are only four lipectomy/liposuction codes and they do not differentiate between the different vendors/techniques/modalities (SAL, WAL, PAL, Ultrasonic) so it’s not necessary to go into detail. Simply describe the procedure as either tumescent, lymph-sparing, or water-assisted liposuction depending on your doctor’s notes and equipment.
Pay careful attention to the listing and Order of all Appendices:
Remove any issue or verbiage that does not address your situation.