Sample Insurance Appeal Letter
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1
2[Date]
[Payer name]
ATTN: APPEALS
[Payer contact name]
[Payer address]
Patient:
[Patient’s first and last name]
Subscriber ID#:
[Insurance ID #]
Subscriber Group #:
[Insurance group #]
Re: PERJETA™ (pertuzumab) Intravenous Infusion
Dates of Service:
[Include all denied dates of service]
Dear Appeals Reviewer:
I am writing to request
[appeal/redetermination/reconsideration]
of the above
denial(s)
of PERJETA for
my patient
[patient name].
I understand from your denial letter that the denials were based on
[denial
reason].
I would like to address
[that reason/those reasons]
now. I would appreciate prompt review of
the enclosed information demonstrating medical necessity and coverage of PERJETA in combination
with trastuzumab and docetaxel for my patient.
Patient’s Clinical History
[Patient’s name]
is a
[age]
year old
[gender]
who was diagnosed on
[date]
with HER2-positive
metastatic breast cancer and has not received prior anti-HER2 therapy or chemotherapy for metastatic
disease.
•
[Include diagnosis and dates]
•
[Any past treatments]
•
[Any test results that indicate failure of past treatment]
•
[Extenuating circumstances that would preclude alternatives to PERJETA]
•
[Social & family information]
[REMINDER: If a payer has a published policy, include here]
[REMINDER: If state statute exists, include here]
Treatment Rationale
PERJETA was FDA approved on June 8, 2012 in combination with trastuzumab and docetaxel for
patients with HER2-positive metastatic breast cancer who have not received prior anti-HER2 therapy
or chemotherapy for metastatic disease. The effectiveness of PERJETA in combination with
trastuzumab and docetaxel in HER2-positive metastatic breast cancer patients who have not received
prior anti-HER2 therapy or chemotherapy for metastatic disease is based on progression free survival.
PERJETA is a recombinant humanized monoclonal antibody that is designed specifically to prevent the
HER2 receptor from pairing with other HER receptors (EGFR/ HER1, HER3 and HER4), a process that
is believed to play an important role in the growth and formation of several different cancer types. By
preventing receptor pairing, PERJETA is thought to block cell signaling, which may inhibit cancer cell
ACS0001180900
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Parent category: Letters