10/14/2015
Horizon Member Appeals
PO BOX 319
Newark, NJ 07101
Explanation of Benefits: <Claim Number>
Dear Sir or Madam:
I am writing to request that you reconsider your payment decision for my Afirma Thyroid FNA Analysis on <Date
of Service>.
Dr. < Dr Name>, biopsied my tumor and the pathology result was “indeterminate,” a classification that is not
clearly benign or malignant. My physician recommended ordering the Afirma test as a next diagnostic step
instead of proceeding immediately to surgery.
As a result of the Afirma test, my tumor was diagnosed as Suspicious increasing my likelihood of having cancer,
and my physician and I were able to make an informed decision on the next steps of my treatment.
I am requesting that you reconsider the payment amount determined for my claim and substantially increase
the amount paid for Afirma. Veracyte has contacted me and shared that they have appealed my claim
requesting further payment with no response. Veracyte also shared that most Horizon members have their
tests paid at rates exceeding $4,000, substantially reducing the amount owed by the patient.
It is inappropriate that there is a discrepancy in the cost sharing amounts between other commercial members
and my claim for the same service. Additionally, I find it unfair that you would arbitrarily subject me to such a
large financial burden. Afirma was able to help my physician decide on the next step in the treatment of my
thyroid disorder. Horizon has a network deficiency for Afirma which is considered medical necessary per
Horizon’s medical policy. Because there is a network deficiency my claim should be paid against my in-network
benefits. If you do not increase the payment for this claim and adjudicate the claim against my in-network
benefits, I will pursue the dispute process with the New Jersey Department of Insurance.
Please include myself and Alicia Kim at Veracyte in all correspondence regarding my reconsideration request.
Sincerely,
<Patient Name>
Subscriber ID: <Subscriber Number>