Sample Letter of Appeal from Patient

We cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payer, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. For additional information, you should consult with your payer for all relevant reimbursement and coverage requirements.

If you choose to use this sample letter, please remove or replace all red text, including this box, before sending.

This letter must be accompanied by a letter of medical necessity from your physician. Following this letter is a sample letter you can provide your physician to facilitate this process.

Sample Letter of Appeal from Patient

Current Date

YourFullName

YourFull Address

YourCity,State andZip

YourPhoneNumberwithAreaCode

InsuranceProvider’sName

InsuranceProvider’sAddress

Insurance Provider’sCity, State, Zip

Dear(insertnameofinsurance providercontact),

I am writing today to appeal the decision to deny coverage for the prescription weight loss medication (insert medication name here) that my physician prescribed. I am asking that you cover this drug because (describe, if applicable,prior attempts to achieve and maintain weight loss). My current weight is ______, my height is______and I am ______years old. I believe that this drug, in conjunction with diet and exercise, offers a chancefor me to achieve meaningful weight loss.

(If applicable, discuss any weight-related conditions that you have, such as high blood pressure, high cholesterol, diabetes, arthritis, sleep apnea, cardiovascular disease, etc. If applicable, list the medications you have been prescribed to treat these weight-related conditions.)

(If applicable, you may choose to include information on how your weight impacts your work and home life.)

I am very hopeful that I can achieve weight loss if you will reconsider your coverage decision for the prescription weight loss medication that my doctor has prescribed.

Please elect to cover this weight loss medication so that I can continue to work toward achieving my weight loss goal. If you will not provide coverage for this medication, please provide a written explanation describing the circumstances under which this medication would be covered by my policy.

Kind regards,

[Attachments: If applicable, consider attaching supporting documentation such as nutritionist’s notes and a personal weight diary.]

Sample Letter of Medical Necessity

Date

Medical Director

Health Plan

Address

Fax:

Physician Name

Physician Address

Physician telephone and fax numbers

Regarding:

Patient Name

Date of Birth

Insurance ID number

Dear Sir or Madam:

I am writing to appeal your decision to deny coverage for the prescription weight loss drug ______for my patient, Mr./Ms.______, who has the following diagnoses relevant to this request: ______. My patient’s current weight is______and his/her height is ______; therefore, the corresponding BMI for this patient is______. My patient suffers from the following weight-related comorbid conditions: ______.

(If applicable, consider including supportive statements to establish medical necessity such as patient’s prior attempts to lose weight.)

Many health organizations and authorities, including the AMA, CDC and the NIH, now recognize obesity as a chronic and progressive, but treatable disease. Additionally, there are several comorbid conditions related obesity, including type 2 diabetes, cardiovascular disease, and hypertension. This should be taken into consideration in your coverage determination for my patient. Please let me know if you require additional information from my records. We look forward to a timely response to this request.

Sincerely,

[Attachments:If applicable, consider attaching supporting documentation such as nutritionist’s notes and/or the patient’s personal weight diary.]