SAMPLE LETTER OF APPEAL
[Please Type on Provider’s Letterhead]
[Insert Date Here]
[Recipient Name]
[Title]
[Company Name]
[Street Address]
[City, ST ZIP Code]
Re: [Insert patient name, subscriber number and date of birth]
To Whom It May Concern:
I received a denial dated [Date] on my patient, [Patient Name], stating the SNaP® Wound Care System is considered [Denial Reason]. Based upon the following information, I am requesting that this claim be reconsidered for coverage and payment.
The SNaP® Wound Care System is the first FDA cleared non-powered and completely disposable negative pressure wound therapy system currently available. The therapy is unlike other NPWT systems, however it holds the same FDA-cleared indications for use that are identical to all electrically-powered negative pressure wound therapy devices being used. Unlike electrically-powered
NPWT systems that are only offered as a DME covered benefit, this system will allow for NPWT to be available as a treatment option that is accessible to patients outside of the home care setting.
Clinically speaking, the SNaP Wound System is able to provide the same level of negative pressure therapy as existing NPWT technologies currently available by [Health Plan Name] as a covered benefit.
This procedure delivers negative pressure through a system that is designed around high energy springs and pistons, rather than depends upon batteries or motors that are needed for other NPWT systems.
The pressure settings and small canister size also mitigates possible safety risks of the powered NPWT such as inappropriate setting adjustments and exsanguination.
Patient History:
[Patient Name] was diagnosed with [Condition] [Months, Weeks, Years] ago.
Describe the patient’s condition in detail including:
 Patient history with a description of patient’s current status including diagnosis, complaints, and level of impairment
 Provide details regarding the severity of condition
 Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life
 Previous treatment efforts - noting procedures, medications, and/or therapies attempted; include outcome of each treatment
 Any social implications for the patient
 Any comorbidities experienced

Proposed CPT Code(s):
CPT Code
97607
Long Descriptor
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
97608 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
Requested Appeal:
[Include statement as to why this NPWT is an appropriate intervention at this point in the patient’s care; note therapeutic goals, anticipated outcomes, duration of prognosis, and rehabilitation potentials.]
I feel the SNaP Wound System is an ideal therapy approach for patients like [Patient Name], who now have access a treatment that previously was unavailable to them as a covered benefit option.
Therefore, in my medical opinion, and based upon the available clinical data to support this therapy, I do believe the SNaP Wound Care System is medically necessary and the best treatment option for my patient at this time.
Sincerely,
[Provider Name]
[Provider Phone Number]
[Provider Fax Number]