Sample Appeal Letter Template printable pdf download

Sample Appeal Letter Template

Sample Appeal Letter

[DATE]

[Insurance Contact Name]

[Insurance Contact Title]

[Name of Insurance Company]

[Insurance Street Address]

[City, ST, Zip code]

Re: Letter of Medical Necessity in Response to Denial of Impella®

Patient Name: [First and Last]

Patient date of birth: [XX/XX/XXXX]

SS#: [XXX-XX-XXXX]

Insurance ID #: [XXXXXXXXXXXXXXX]

Group #: [XXXXXXXXXX]

Claim #: [XXXXXXXXXX]

Date of Service: [XXXXXXXXX}

Dear [Insurer]:

I am writing this letter in response to the above referenced denied claim to provide

clinical justification for [patients name]’s Impella® procedure.

Physician/Facility Free Text:

Establish the risk profile of the patient

Mention patient case history and condition prior to the procedure, if patient was a

surgical turndown

Coronary anatomy risk (RCA, LAD, triple vessel disease, etc.)

Establish the hemodynamic profile prior to Impella (this can be provided by the

physician)

Note any additional MCC’s and CC’s to support the need for hemodynamic support

Note if other hemodynamic support alternatives were used and if patient is refractory to

these interventions

Technical work value of the physician

Clinical benefits to patient

Expected outcome if Impella® was not provided

If you have any questions regarding the material that has provided, please contact me.

Thank you for your prompt attention to this matter.

Sincerely,

[Person requesting appeal}

Sample Appeal Letter Template