Appeal Letter: Medication/Treatment
SAMPLE
INSURER
RE:
PATIENT
ID No.
Dear Sir or Madam:
I am writing to appeal the denial of coverage for the Adalimumab therapy for PATIENT.
In the denial letter, INSURER found that the “request cannot be approved because this
medication is considered investigational when used for the treatment of pediatric Crohn’s Disease and is
therefore a contract exclusion.” However, there is extensive medical literature that proves that
adalimumab (ADA) therapy is an effective treatment for Crohn’s disease in patients who are allergic or
intolerant to infliximab, which is currently conventionally used medication for Crohn’s Disease.
In this case, ADA therapy is medically necessary. PATIENT has been tried on (specify
treatment) in the past, with failure to control her/his disease. She/he has thus had to endure the symptoms
of Crohn’s Disease, such as abdominal pain and cramping, diarrhea, and fatigue – all symptoms that a
child her age should not be required to live with. ADA therapy is necessary and she/he is an ideal
candidate for such therapy. Thus, this appeal should be granted.
Numerous peer-reviewed articles demonstrate that patients with Crohn’s Disease previously allergic or
intolerant to infliximab actually respond favorably to the treatment of ADA, see Konstantinos A.
Papdakis et al., Safety and Efficacy of Adalimumab (D2E7) in Crohn’s Disease Patients with an
Attenuated Response to Infliximab, 100 AM. J. GASTROENTEROLOGY 75 (2005). Other reliable
studies found that ADA is well-tolerated and effective rescue therapy for moderate to severe pediatric CD
patients previously treated with infliximab, see Rosh JR et al., Retrospective Evaluation of the Safety and
Effect of Adalimumab Therapy (RESEAT) in Pediatric Crohn’s Disease (2008)
I am enclosing a set of PATIENT’S medical records. These records show the following.
(State key medical findings and patient current condition)
The progression of his/her disease has prevented PATIENT from carrying on the normal daily activities
of a X year old boy/girl, and the symptoms of her Crohn’s Disease in combination with the constant
hospital visits have taken both a physical and emotional toll.
In short, neither the diagnosis nor the severity of symptoms is in question, nor is there doubt that
the alternative medical treatments have failed. PATIENT’S best chance for relief and the most
appropriate course of treatment is the adalimumab therapy.
I request approval of XX mg per week of adalimumab therapy for PATIENT.
Please contact my office if you have additional questions.
Sincerely,
Name
Contact Information
Appeal Letter: Medication/Treatment