About Food Allergies

Sample Letter of Appeal for Denial of Coverage

Name
Address

Date

Address of claims review department

Name of patient:
Plan ID #:
Claim #:

Dear Claims Review Department:

I am writing to you in regards to coverage denial for the prescription drug [insert epinephrine auto-injector brand here].

This prescription drug is medically necessary for [my, my child’s] condition and is recommended and prescribed by my physician. Epinephrine is the only medication that can reverse the symptoms of a severe life-threating allergic reaction, known as anaphylaxis.

I am requesting that [health insurer name] reconsider this denial and cover the cost of the medication. Your denial of this claim puts [my, my child’s] life in danger.

I am enclosing a letter of medical necessity from the physician who prescribed this medication. Please review this information and contact me or my physician if there is additional supporting information you require to make a decision. Thank you for your time and assistance in this matter.

Sincerely,
NAME / SIGATURE
Include your phone and email

Sample Letter of Medical Neccesity

Physician Name
Address

Date

Address of claims review department

Name of patient:
Plan ID #:
Claim #:

To Whom It May Concern:

I am writing on behalf of my patient, (patient name), to document the medical necessity of an epinephrine auto-injector for the treatment of a food allergy/allergies.

This letter provides information about the patient’s medical history and diagnosis and a statement summarizing the need for an epinephrine auto-injector.

Patient’s History and Diagnosis:

(Include information here regarding the patient’s condition and specific diagnosis. Also include the patient’s history related to their condition, if applicable)

Medication Rationale:

(Include information on why the medication is necessary)

In summary, an epinephrine auto-injector is medically necessary for this patient’s health and safety. Please contact me if any additional information is required to ensure the prompt approval of the epinephrine auto-injector.

Sincerely,
(Physicians name and signature)

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