Sample letter to health plan on behalf of a patient
You may copy or print this letter to use as a model. Note: This letter is only an example. Please edit the letter to suit your needs. This page can also be downloaded as a PDF Document.
(Tip: if you don’t have the contact information for the medical director of your patient’s health plan, check to see if it’s listed under our health plan directory.)
[Today's date]
[Name of medical director]
[Name of insurance company]
[Street address]
[City] [State] [ZIP code]
Dear [name of medical director],
I am contacting you on behalf of my patient, [name of patient] [Insurance ID #]. [Name of health plan] has denied his/her claim for [name oftherapy/drug] for his/her psoriasis and/or psoriatic arthritis.
Please consider this letter a formal, written appeal of your denial of this medically necessary therapy. [Name of patient] has been my patient for [amount of time] (months/years) and I have worked with him/her extensively to improve his/her psoriasis and/or psoriatic arthritis. In view of [name of patient]'s signs, symptoms and history, I have determined that [name of therapy/drug] is medically necessary. [Explain the benefit/efficacy of the therapy/drug to specific patient and patient's history here.]
As you may know, psoriasis—and the psoriatic arthritis that accompanies it in as many as 30 percent of cases—is a genetic disease of the immune system for which there is no cure. Although psoriasis reveals itself on the skin, there is also a significant negative impact on daily functioning and psoriasis puts patients at increased risk for other serious diseases such as heart attack and diabetes.1,2 Psoriatic arthritis involves the joints and can add to dysfunction. Researchers have found that psoriasis causes as much disability as other major diseases, such as cancer, arthritis, hypertension, heart disease, diabetes and depression.3 Without proper treatment, psoriasis and psoriatic arthritis can be physically and emotionally devastating, preventing the carrying out of normal activities, affecting productivity at work and reducing quality of life.4
The American Academy of Dermatology (AAD) has published guidelines for the care of psoriasis and psoriatic arthritis. For an overview of psoriasis, its co-morbidities and an evaluation of psoriasis treatments, please visit:
.
If you have any further questions regarding this patient, please do not hesitate to contact me.
Sincerely,
[Physician name]
[Physician address]
[City] [State] [ZIP code]
[Phone number]
| CC: | [Name of patient]
National Psoriasis Foundation |
1 Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. Journal of the American Medical Association. 2006;292(14):1735-1741.
2 Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. Journal of the American Academy of Dermatology. 2006;55(5):829-35. Epub 2006 Sep 25.
3 Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM. Psoriasis causes as much disability as other major medical diseases. Journal of the American Academy of Dermatology. 1999;41(3 Pt 1):401-7.
4 Young M. The psychological and social burdens of psoriasis. Dermatology Nursing. 2005;17(1):15-9.
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