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What Should I Include in My Appeal to My Insurance Company?    Print Page

The following three items should be included in your patient appeal submission to the insurance company:

  1. An appeal letter addressing the reason for denial as provided in the insurance company’s denial letter. Include the following information in your letter to your insurance company:
  • Date you were diagnosed with chronic severe asthma 
  • List of asthma medications that you currently take and in spite of taking the medicine as prescribed by your doctor you continue to have asthma symptoms 
  • Number of visits the Emergency Room (ER) for asthma and number of times you had to check into the hospital over the past year
  • Number of doctor office visits over the past year for asthma
  • Impact of asthma on your quality of life (describe what you are unable to do because of your asthma, like how it affects your ability to work or exercise)
  • Include a copy of your insurance bills for all asthma services, procedures, and visits.  Add up the total cost of care and include this dollar amount in your letter.

Sample Patient Letter of Appeal     

This is a sample appeal letter that can be used to support your efforts to appeal a denied pre-determination request by your doctor.  Make sure to read the explanation from your insurance company as to why they are denying your request and address it in your appeal.

    2.   Supporting letter from doctor/specialist detailing:

  • your diagnosis
  • your medical history 
  • what treatments have been tried but have been unsuccessful
  • a summary of the research published on the safety and effectiveness of the requested treatment procedure or service and why it is medically necessary for you.

Sample Doctor Supporting Appeal Letter   

Ask your doctor to write a letter to support your coverage request.   It is critical that the doctor include the clinical justification for your appeal – brief description of the procedure, why it is medically necessary and reference the supporting data from publications on the procedure’s efficacy. 

  1. Copies of peer-reviewed clinical articles supporting the safety and efficacy of the treatment procedure or service. 

Sample Supporting Materials for Appeal

  • Peer-reviewed Articles

It is important to include copies of peer-reviewed clinical articles that demonstrate the safety and efficacy of the procedure or service.  It is especially critical to provide this supporting objective material for newer procedures.

For example, below is a list of bronchial thermoplasty publications and links to the full papers.  You may print these publications free of charge and include them in your appeal.

  1. Castro M, et al. Effectiveness and Safety of Bronchial Thermoplasty in the Treatment of Severe Asthma: A Multicenter, Randomized, Double-Blind, Sham-Controlled Clinical Trial. American Journal of Respiratory & Critical Care Medicine 2010;181: 116-124. http://ajrccm.atsjournals.org/cgi/reprint/181/2/116.pdf

  2. Castro M, et al.  Persistence of Effectiveness of Bronchial Thermoplasty in Patients with Severe Asthma.  Annals of Allergy, Asthma & Immunology,2011 Jul;107(1):65-70. http://www.cenveomobile.com/issue/35148

  3. Pavord I, et al. Safety and Efficacy of Bronchial Thermoplasty in Symptomatic Severe Asthma. American Journal of Respiratory & Critical Care Medicine 2007; 176: 1185-1191. http://ajrccm.atsjournals.org/cgi/reprint/176/12/1185.pdf
  • Food and Drug Administration (FDA) Approval Letter

If your appeal is about a particular device (machine, tool or appliance) or medicine, it may be helpful to provide the insurance company with a copy of an FDA approval letter.  The FDA approval letter demonstrates that the FDA, in its role as the U.S. regulatory agency, has approved the device or medicine to be safe and effective. 

Premarket Approval (PMA):  Premarket approval is the FDA process of scientific and regulatory review to evaluate the safety and effectiveness of class III medical devices.

To find a copy of the approval letter for a certain device, you can search the FDA website under the Approvals & Clearances section at http://www.fda.gov/MedicalDevices/default.htmEnter the name of the device and select “Approval Order” to get a copy (in PDF format) of the approval letter.

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm

For example, here is the link to the bronchial thermoplasty FDA approval letter.

http://www.accessdata.fda.gov/cdrh_docs/pdf8/P080032a.pdf

  • Positive Technology Assessment Reviews 

Technology assessment organizations identify medical technologies supported by scientific evidence that improve health.  Their purpose is to bring objectivity and transparency regarding new technologies to the U.S health care delivery system.  Technology assessments are often referred to by insurance companys when they make their coverage policies.

For example, here is a link to the report published by the California Technology Assessment Forum (CTAF) stating that bronchial thermoplasty, when performed in patients with poorly controlled severe persistent asthma, meets its five technology assessment criteria. 

http://www.ctaf.org/content/assessment/detail/1381 

 
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