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APPEAL TEMPLATE LETTER #3
SECOND LEVEL APPEAL/REQUEST FOR EXTERNAL REVIEW OF EUSTACHIAN TUBE BALLOON DILATION
[INSERT OFFICE LETTERHEAD]

[INSERT INSURANCE NAME]
[INSERT INSURANCE ADDRESS]
[INSERT CURRENT DATE]
Re:

[PATIENT NAME]
[PATIENT IDENTIFIER FOR PAYOR]
[IDENTIFYING INFORMATION FOR PAYOR – GROUP, POLICY OR CLAIM NUMBER]
[DATE OF BIRTH]

Dear [INSERT INDIVIDUAL, DEPARTMENT OR PAYOR NAME],
It is our understanding that the [INSERT LEVEL 1 OR LEVEL 2] Appeal related to the above-referenced patient
was denied. Please accept this [LEVEL 2 APPEAL OF THIS DECISION] [OR OUR REQUEST FOR EXTERNAL EXPERT
REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION].
Please be advised that this patient’s treatment plan was developed with conscientious consideration for their
unique medical condition and the current standards of quality care for persistent Eustachian tube dysfunction
(ETD). Your response to our [FIRST OR SECOND] appeal does not specifically address an in depth discussion of
this patient’s i