Dear Health Care Provider:
We have provided this sample Letter of Appeal to assist with a prior authorization denial for Otsuka
product. Use of this document does not guarantee coverage for the medication for your patient.
To use this letter, please copy the text from page 2 and paste it onto your office letterhead. Be sure to
replace all bolded and bracketed text with the appropriate patient-specific information before forwarding
your customized letter to your patient’s insurance provider. If the provided fields do not accurately
reflect your practices, please modify them to represent your particular circumstances.
Tips for completing the disease and medical history fields:
Include specific diagnosis codes where appropriate
List previous therapy, length of therapy, and outcomes (i.e., specify reasons for unsuccessful
Clearly state the rationale for the recommended therapy and why it is appropriate for your
Tips for completing the enclosed materials field: