Appeal letter sample: Pediatric Adalimumab Therapy


Template letter for professionals to complete so parents of pediatric patients taking adalimumab may appeal insurance denials. Healthcare provider completes letter and parent submits to their insurance company.

SAMPLE LETTER BELOW

INSURER

RE:      PATIENT

            ID No.

Dear Sir or Madam:

I am writing to appeal the denial of coverage for the Adalimumab therapy for PATIENT.

In the denial letter, INSURER found that the “request cannot be approved because this medication is considered investigational when used for the treatment of pediatric Crohn’s Disease and is therefore a contract exclusion.”  However, there is extensive medical literature that proves that adalimumab (ADA) therapy is an effective treatment for Crohn’s disease in patients who are allergic or intolerant to infliximab, which is currently conventionally used medication for Crohn’s Disease. 

In this case, ADA therapy is medically necessary.  PATIENT has been tried on (specify treatment) in the past, with failure to control her/his disease.  She/he has thus had to endure the symptoms of Crohn’s Disease, such as abdominal pain and cramping, diarrhea, and fatigue – all symptoms that a child her age should not be required to live with.  ADA therapy is necessary and she/he is an ideal candidate for such therapy.  Thus, this appeal should be granted.

Numerous peer-reviewed articles demonstrate that patients with Crohn’s Disease previously allergic or intolerant to infliximab actually respond favorably to the treatment of ADA, see Konstantinos A. Papdakis et al., Safety and Efficacy of Adalimumab (D2E7) in Crohn’s Disease Patients with an Attenuated Response to Infliximab, 100 AM. J. GASTROENTEROLOGY 75 (2005).   Other reliable studies found that ADA is well-tolerated and effective rescue therapy for moderate to severe pediatric CD patients previously treated with infliximab, see Rosh JR et al., Retrospective Evaluation of the Safety and Effect of Adalimumab Therapy (RESEAT) in Pediatric Crohn’s Disease (2008)

I am enclosing a set of PATIENT’S medical records.  These records show the following.

(State key medical findings and patient current condition)

The progression of his/her disease has prevented PATIENT from carrying on the normal daily activities of a X year old boy/girl, and the symptoms of her Crohn’s Disease in combination with the constant hospital visits have taken both a physical and emotional toll.

In short, neither the diagnosis nor the severity of symptoms is in question, nor is there doubt that the alternative medical treatments have failed.  PATIENT’S best chance for relief and the most appropriate course of treatment is the adalimumab therapy.

I request approval of XX mg per week of adalimumab therapy for PATIENT. 

Please contact my office if you have additional questions.

Sincerely,

Name

Contact Information



For further information, call CCFA at our Information Resource Center: 888.MY.GUT.PAIN (888.694.8872).

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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