Sample Letter Of Appeal Template

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HYALGAN SAMPLE LETTER OF APPEAL
Below is a sample, template letter of appeal that may be customized with patient-specific information and
submitted to payers for reconsideration of denied claims. For additional assistance, please call The
HYALGAN Support Hotline at 1.866.7.HYALGAN (1.866.749.2542), Monday to Friday, from 9:00 am to 8:00
pm EST.
[Date]
[Name of Medical Director]
[Insurer Name]
[Address]
[City, State, Zip Code]
Re: [Patient Name]
[Patient ID Number]
[Claim Number]
Dear Dr. [Name of Medical Director]:
I am writing to formally appeal a denied claim for services provided to [insert patient’s name, ID number, and
claim number]. Based on a clinical assessment of my patient, the patient’s diagnosis, and medical history,
HYALGAN
®
(sodium hyaluronate) therapy is medically necessary. This letter provides my clinical rationale
for HYALGAN therapy. It presents information about this patient’s medical condition and explains why it is
medically necessary and appropriate for this patient.
[Insert patient’s case history, including the patient’s condition and clinical course prior to HYALGAN therapy.]
Based on the clinical evidence for this case, HYALGAN therapy is medically necessary. Accordingly, this
claim should have been approved for payment.
I hope that this letter has been helpful in explaining the necessity and value of HYALGAN therapy for this
patient. I have enclosed the following documents to assist you in your reconsideration of this claim:
• A copy of the denied claim;
• Clinical literature on HYALGAN therapy and the clinical benefits; and
• [any additional, relevant information to support the appeal, such as medical notes or payer policy].
Thank you for your reconsideration of coverage for this patient’s treatment. Please call me at [insert phone
number] if additional information is required.
Sincerely,
[Physician’s name]
1
FID338-02.2016-7

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