LETTER OF APPEAL
Note: This example is for instructional use only. Use the form provided by the payor, if available.
Include all insurance company information, including the contact in
Appeal for coverage of VENTAVIS® (iloprost) Inhalation
Solution 2.5 mcg with 10 mcg/mL, 5.0 mcg with 10
Include all patient information, including health insur
mcg/mL, 5.0 mcg with 20 mcg/mL
Name of insured:
Reference ID, if available:
Include your information, including contac
Dear [Claims Representative]:
I am writing to request a review of a denied claim for [Patient name]. Your Cite reasons from payor response.
company has denied this claim for the following reason(s): [Fill in reason(s)
from Explanation of Benefits (EOB)].
[Patient name] was provided VENTAVIS® (iloprost) Inhalation Solution therapy
for the treatment of pulmonary arterial hypertension (PAH, WHO