Appeal letter sample: Certolizumab Pego Boost


Template letter for professionals to complete so patients may appeal insurance decisions related to the dosing of certolizumab. Healthcare provider completes letter and patient submits to their insurance company.

SAMPLE LETTER BELOW

Date

Insurance Company

 

RE:      John Doe   

            ID no.

            Service: certolizumab pegol booster dose

            Date of service: prior authorization

Dear Sir/Madam

I am writing on behalf of Mr/Ms. Doe to request prior authorization for a dose escalation or “booster dose” of certolizumab pegol and to provide you with detailed medical information to support the  one time extra dose to get Mr/Ms Doe back into remission.

Mr/Ms. Doe responded to the induction dosing with certolizumab pegol and then lost response after being on maintenance doses for XX months/years.  He/She is now suffering the beginning of a flare of his/her Crohn’s disease.  He/she is now, having  X loose stools per day, abdominal pain, fevers,  (describe of symptoms).   The most conservative course of action would be a booster dose of 400 mg sc to enable Mr./Ms Doe to recapture his/his remission and avoid steroids or surgery  Again, certolizumab pegol has worked well for him/her bymaintaining steroid free remission for  X months/years.

Data from a group of patients who lost response during the PRECiSE 2 trial suggest that a single re-induction dose with certolizumab pegol 400 sc mg may re-establish response..  The data indicated that 58% of people allowed the one time dose escalation went back into remission. [Lichtenstein et al. 2008].  Mr/Ms. Doe has been on cetrolizumab pegol for x years/months with truly outstanding results..  He/she had been in a complete remission, having only X formed stools per day, was free from abdominal pain and was working (going to school) without absences.

Please approve this request for a one time booster dose of 400 mg sc of certolizumab pegol and allow Mr/Ms Doe to enjoy the return to a productive life free from the symptoms of moderate to severe Crohn’s disease. 

Please contact me at (xxx) xxx-xxxx if any additional information will help clarify this request. 

Sincerely,

Dr.
Address
Contact Info

 

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The Crohn’s & Colitis Foundation of America provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product.

About this resource

By: CCFA
Published: May 1, 2012

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Certolizumab pegol boost (.doc)
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