Sample Physician's Statement of Medical Necessity
(Submit to Payer with Request for Prior Authorization or Claim)
Date
Payer Name
Payer Address
City, State Zip
Patient Name:
Policy Number:
Dear Claims Representative:
I am writing on behalf of my patient, (insert patient's name and policy number), to request that (name of health insurance company) approve coverage for (explanation of therapy, treatment, service, etc.) in relation to their diagnosis of (patient diagnosis).
This letter provides information regarding this patient's medical history, diagnosis, and treatment plan and confirms the medical necessity and appropriateness of this prescribed treatment.
Pulmonary hypertension (PH) is a rare condition characterized by increased blood pressure in the pulmonary artery. When pulmonary hypertension occurs in the absence of a known cause, it is referred to as Idiopathic Pulmonary Hypertension (IPAH). PPH is extremely rare, occurring in about two persons per million populations per year. Secondary pulmonary hypertension (SPH) is commonly caused by breathing disorders such as emphysema and bronchitis. Other causes may include scleroderma or CREST syndrome. Pulmonary hypertension is an incurable and progressive illness with few treatment options. (Insert name of treatment) has been shown to significantly improve prognosis.
Patient's History and Diagnosis
(INSERT INFORMATION REGARDING PATIENT'S HISTORY WITH THIS
DISEASE, INCLUDING PREVIOUSLY ATTEMPTED TREATMENTS AND RESULTS.)
Based on the above information, please provide coverage for these submitted charges. This (treatment/service) is medically necessary for this patient in order to treat (his/her) diagnosis. If you require any additional information, please contact me at (insert physician's telephone number).
Sincerely,
(Provider's Name)
Sample Claim Denial Appeal Letter
(From Provider to Payer)
Date
Payer Name
Payer Address
City, State Zip
Patient Name:
Policy Number:
Dear Claims Representative:
I am writing on behalf of my patient (insert patient name) to request reconsideration of payment of a denied claim for (insert name of treatment).
You have indicated that (insert name of treatment) is not covered by (insert payer name) because of (insert reason given). This medication has been prescribed for (insert patient name) based on their diagnosis of (insert diagnosis information).
Pulmonary hypertension (PH) is a rare condition characterized by increased blood pressure in the pulmonary artery. When pulmonary hypertension occurs in the absence of a known cause, it is referred to as idiopathic pulmonary hypertension (IPAH). PPH is extremely rare, occurring in about two persons per million populations per year. Secondary pulmonary hypertension (SPH) is commonly caused by breathing disorders such as emphysema and bronchitis. Other causes may include scleroderma or CREST syndrome. Pulmonary pypertension is an incurable and progressive illness with few treatment options. (Insert name of treatment) has been shown to significantly improve prognosis.
History and Diagnosis
(INSERT INFORMATION REGARDING PATIENT'S HISTORY WITH THIS
DISEASE, INCLUDING PREVIOUSLY ATTEMPTED TREATMENTS AND RESULTS.)
Based on the above information, I would appreciate your reconsideration of coverage for these submitted charges. (Insert name of treatment) is medically necessary in order to treat this patient's diagnosis of (insert diagnosis information). If you require any additional information, please contact me at (insert physician's telephone number).
Sincerely,
(Provider's Name)
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
