Sample Letter Template Of Medical Necessity For Astellas Products printable pdf download

Sample Letter Template Of Medical Necessity For Astellas Products

SAMPLE LETTER TEMPLATE OF MEDICAL NECESSITY

FOR ASTELLAS PRODUCTS

To Prescriber: Please refer to the important safety information in the full Prescribing Information,

including any Boxed Warning, when determining whether therapy is medically appropriate for the

individual patient.

[Date]

[Contact Name]

[Insurance Company]

[Insurance Company Address]

[City, State ZIP Code]

[Fax Number]

ATTN: Prior Authorizations / Appeals

Re:

Coverage of [Astellas Product Name / generic name /dosage form]

[Patient First Name] [Patient Last Name]

[Policy Number]

[Group Number]

[Patient Date of Birth]

Diagnosis: [Diagnosis]

To whom it may concern:

I am submitting this letter to document the medical necessity of [Astellas Product Name] for [Patient

Name]. [Astellas Product Name] is indicated for the treatment of [insert FDA approved indication].

[Patient Name] has been diagnosed with [Diagnosis] [insert any additional criteria necessary for on‐label

treatment] and has been receiving treatment for this diagnosis.

[Describe the patient’s history, including diagnostic test results, previous and current treatment

regimens and their outcomes]

Based on the information provided above, I have determined that treatment with [Astellas Product Name]

is medically necessary and reasonable for [Patient Name]. Enclosed are copies of [Patient Name]’s

medical records documenting related symptoms and medical necessity, as well as the Full Prescribing

Information for [Astellas Product Name]. Please approve coverage for [Astellas Product Name] for

[Patient Name] as recommended. Thank you for your prompt attention to this matter. If I can provide

any additional information, please contact me.

Regards,

[Physician Name]

[NPI Number]

[Phone Number]

[Fax Number]

080‐1133‐PM 12/16

Sample Letter Template Of Medical Necessity For Astellas Products