Free appeal letter 35
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Sample Appeal Letter
[Date]
ATTN: Medical Review/Appeals
[Name of Payer] [Address
of Payer]
Patient: [First and last name] Member ID: Member Group #: Rx Bin#: Explanation of Benefit #:
®

Re: Request for Reconsideration of Qsymia (phentermine and topiramate extended-release)
capsules CIV use for [patient’s name]
To Whom It May Concern:
®

I am writing on behalf of my patient, [patient’s name], who was denied coverage of Qsymia
(phentermine and topiramate extended-release) capsules CIV on [date of denial]. The denial
reason was stated as [not medically necessary, not covered on the formulary, etc]. I am requesting
a redetermination of the denial of coverage for Qsymia and have enclosed documentation that
supports the use of this FDA-approved medication for this patient.
[Outline the patient’s history, diagnosis, and treatment plan. Provide rationale for Qsymia
treatment.]
In conclusion, please reconsider the denial Qsymia for my patient, [patient’s name]. I would
appreciate prompt revie