HTML Preview Appeal Letter Sample For Medical Necessity page number 1.


APPEAL LETTER OF MEDICAL NECESSITY AFTER DENIAL OF GENETIC TESTING
____________________________________________________________________________________
INSURANCE COMPANY ADDRESS
SUBSCRIBER NAME
SUBSCRIBER ID
PATIENT NAME
BIRTHDATE
Date:
To whom it may concern,
I am writing this letter on behalf of my patient, PATIENT NAME, to appeal the denial of coverage for
genetic testing offered through the Center for Precision Diagnostics, a CLIA certified laboratory located
at the University of Washington in Seattle, Washington. This letter documents the medical necessity for
this test to identify the genetic cause of NAME OF DISORDER condition and provides information about
PATIENT NAME medical and family history, and treatment to date.
PATIENT NAME is an AGE year old SEX with a diagnosis of NAME OF DISORDER (ICD-9 XXXXXX)
DESCRIBE DISORDER
PATIENT NAME has been evaluated by numerous specialists at INSTITUTION, INSTITUTION. PATIENT
NAME has had extensive medical testing including, but not limited to, DESCRIBE PERTINENT TESTING TO
DATE. None of these physicians or tests has provided NAME OF PATIENT with a diagnosis.
The fact that HE/SHE has PARTICULAR FEATURES OF THE DISORDER (E.G. BILATERAL, WIDESPREAD,
MULTIPLE SYSTEMS) is strongly indicative of a genetic etiology, since they did not occur following
medication or infection or other exogenous cause. This personal and family history, as well as PATIENT
NAME’s examination, are not consistent with any known DISEASE CATEGORY conditions, but are
indicative of an underlying genetic cause.
The most efficient and cost effective way to confirm a genetic diagnosis in this patient is to perform LIST
GENES genetic testing. Results from this genetic test will have a direct impact on this patient’s
treatment and management and will provide prognostic information that will assist in clinical
management.
As mentioned above, knowledge of this patient's genetic information is important for me to more
accurately assess her prognosis and will guide my recommendations for care.
To summarize, I am requesting to appeal XXXs denial for genetic testing through the Collagen Diagnostic
Laboratory, Federal Tax ID #: 91-1220843/NPI #: 102 304 1159 with the following CPT code(s):[CPT
CODES AVAILABLE AT www.uwcdl.org]. Thank you for your review and consideration. I hope you will
support this letter of medical necessity for XXX. Please feel free to contact me at XXXXXX if you have
additional questions.
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