Insurance Company
John Doe
ID no.
Service: Stool test - Calprotectin
Date of service: prior authorization
Dear Sir or Madam:
I am writing this letter in regards to my patient, John Doe, who I follow at the City
Medical Center for care of his Crohn’s disease/ulcerative colitis. I am requesting
approval for stool test (s) for calprotectin.
Mr. Doe has Crohn’s disease/ulcerative colitis and has a reoccurrence of disease
symptoms three times in the past 12 months. I would like order calprotectin stool test to
monitor his inflammation and to help to predict the course of IBD. I request prior
authorization to order stool test (s) and to provide you with detailed medical information
to support the change.
Roda, et al 1 indicate that calprotectin is the best-characterized fecal marker of intestinal
inflammation and seems to represent a good predictor of relapse in patients affected by
inflammatory bowel disease (IBD). Calprotectin and other biomarkers are not only
useful in predicting IBD activity but, they are also present in other gastrointestinal
diseases. This stool test is helpful in guiding more invasive testing, detecting flares, and
in optimizing medical therapy.
Please approve this request for calprotectin. Contact my office at (xxx) xxx-xxxx if any
additional information will help clarify this request.
Contact Info
Disclaimer: The sample appeal letters available to prescribing physicians on this
website may include use of agents for conditions other than their FDA indications.
CCFA does not endorse the use of any pharmaceutical agent, including any use which is
outside the labeled indication. CCFA provides this service for informational purposes
only. CCFA, its agents, officers, employees and volunteers shall not be liable for any
claims, damages or actions whatsoever which may arise for the use of this information.
(Remove disclaimer prior to submission of recipient)
Roda G; Caponi A; Benevento M, et al. New Proteomic Approaches for Biomarker Discovery in
Inflammatory Bowel Disease. Inflamm Bowel Dis ,Volume 16, Number 7, July 2010, 1239-1246
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