Letter Of Appeal Template
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1Letter of Appeal
Date:
To:
Insurer Name
Insurer Address
City / State / Zip Code
ATTN: Claims Department
Re:
Patient’s Name:
Patient's Name
Policy Number:
Policy Number
Treatment Date(s):
Include all dates of service
Amount:
Give total dollar amount of charges filed
Dear Director of Claims,
The above referenced claim was denied on__________despite the fact that our office
Date
verified benefits and obtained prior authorization of care from your plan on __________.
Date (PA)
Mr./Mrs. Patient Last Name
Patient's Diagnosis
________________________ has been treated for_____________________________
with the following treatment modalities:
Provide all treatment modalities used, dates of service, and outcomes
Apligraf
has been shown to heal more wounds faster than conventional therapy alone in
®
patients with venous stasis and diabetic foot ulcers. To date,_____________________’s
Mr./Mrs. Patient Last Name
wound(s) has gone from __________________________________________________.
Provide wound dimensions prior to treatment, and current dimensions
Mr./Mrs. Patient Last Name
It is my belief that________________________ has benefited from Apligraf therapy, and
therefore the services rendered should be covered under his/her plan. Please feel free to
contact me if you require additional information to reconsider your coverage decision.
Sincerely,
Physician's Name
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Parent category: Letters