Sample Format Letter Of Appeal printable pdf download

Sample Format Letter of Appeal

[Date]

[Contact Name]

Re: [Patient First Name] [Patient Last Name]

[Insurance Company]

[Policy Number]

[Insurance Address]

[Group Number]

[Insurance City, State Zip]

[Diagnosis]

Dear [Name or Contact]:

This letter serves as a formal appeal for reconsideration of coverage for Rubraca™ (rucaparib) [include the

dosage form (tablets)], which was originally denied to [Patient First Name] [Patient Last Name], on [Date of

Denial]. [Patient First Name] [Patient Last Name], has been under treatment for [Diagnosis] since [Date of

Onset]. [Insurance Company Name] has stated that Rubraca is not covered because [Denial Reason].

Treatment Information

RUBRACA is a poly (ADP-ribose) polymerase (PARP) inhibitor indicated as monotherapy for the treatment

of patients with deleterious BRCA mutation (germline and/or somatic) associated advanced ovarian cancer

who have been treated with two or more chemotherapies. Select patients for therapy based on an FDA-

approved companion diagnostic for RUBRACA. This indication is approved under accelerated approval

based on objective response rate and duration of response. Continued approval for this indication may be

contingent upon verification and description of clinical benefit in confirmatory trials.

Patient History and Diagnosis

[Patient First Name] is a [Age]-year-old female who has been under treatment for [Diagnosis] since [Date].

During this time, she has been treated with other therapies including [discuss previous therapies and patient’s

response to therapy]. [Insert Pertinent Patient Medical History, including diagnostic test results, patient’s

quality of life, and information regarding the patient’s disease state by assessment tools/scales if

applicable.]

Based on the information provided above, I have determined that treatment with Rubraca is medically necessary

for [Patient First Name] [Patient Last Name]. I respectfully request that [Insurance Company Name] reconsider

providing coverage for Rubraca for this patient.

Please call me at [Primary Treating Site Phone Number] if you require additional information pertinent to this

appeal.

Sincerely,

[Treating Provider First Name] [Treating Provider Last Name], [Treating Provider Title]

PP-RUCA-US-0085

Sample Format Letter Of Appeal