Date
Insurance Company
RE:
John Doe
ID no.
Service: Infliximab dose escalation
Date of service: prior authorization
Dear Sir/Madam
I am writing on behalf of Mr/Ms Doe to request prior authorization to increase the current
infliximab dose and to provide you with detailed medical information to support the
change. I am requesting to increase the current dose from 5mg to 10mg in an effort to
recapture Mr/Ms Doe’s remission.
Increasing the dosage from the current 5 mg/kg to 10 mg/kg will result in significant
improvement in Mr/Ms Doe’s symptoms. Mr/Ms Doe has been on 5 mg of infliximab for
nearly x years/months with excellent results. He/She has been in a complete remission,
having only X formed stools per day and no abdominal pain or cramping (describe
symptoms of previous flares)
Mr/Ms Doe is losing hi/her response to infliximab at 5 mg/kg and, thus, he/she is
suffering the beginning of a flare of his/her Crohn’s disease/ulcerative colitis, having X
to X loose stools per day (describe of symptoms).
A trial of a higher dosage of
infliximab would allow for a return to remission while avoiding steroids and/or surgery
(Summarize patient’s current treatment history and enclose supporting
information)
Regueiro et al 1 studied Crohn’s disease patients who required dose intensification,
defined as either an increase in infliximab dose or a decrease in infusion interval. All
study participants received at least 8 doses. At 30-months from initial infusion, 69.1 % of
all patients were event-free from an interval decrease, 48.5% were event-free from a
dose increase, and 45.7 were event-free for dose intensification.
Shih et al 2 did a retrospective analysis of Crohn’s patients who received infliximab over
a five year period. Forty eight percent (48%) of patients required an increase in dosage
and/or a decrease in interval to maintain response. Specifically, a dose increase to 10
mg/kg to maintain response in 32% of patients and a decrease in interval in 27% of
patients.
Infliximab worked very well for Mr/Ms Doe in inducing and maintaining remission for
nearly X months/years. Administration of an increased dosage will likely get the flare
under control and get Mr/Ms Doe back into steroid free remission Please approve this
request of an increased dosage of infliximab to re-induce remission and allow Mr/Ms
Regueiro M, Siemanowski B, Kip K, et al. Infliximab dose intensification in Crohn’s disease. Inflamm
Bowel Disease. Published online first May 4, 2007; doi:10.1002/ibd.20177.
2
Shih GE, Bayless TM, Harr ML. Maintenance of long term response to infliximab over 1 to 5 years in
Crohn’s Disease including shortening dosing intervals or increasing dosage. [Abstract]. Digestive Disease
Week, May 16-19, 2004. New Orleans, LA. Abstract 104672.
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Doe A return to a productive life free from the symptoms of his/her inflammatory bowel
disease.
Please contact me at (xxx) xxx-xxxx if any additional information will help clarify this
request.
Sincerely,
Dr.
Address
Contact Info
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