Free appeal letter 34
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Sample Appeal Letter
[DATE]
[Insurance Contact Name]
[Insurance Contact Title] [Name
of Insurance Company]
[Insurance Street Address]
[City, ST, Zip code]
Re: Letter of Medical Necessity in Response to Denial of Impella® Patient
Name: [First and Last]
Patient date of birth: [XX/XX/XXXX]
SS#: [XXX-XX-XXXX]
Insurance ID #: [XXXXXXXXXXXXXXX]
Group #: [XXXXXXXXXX]
Claim #: [XXXXXXXXXX]
Date of Service: [XXXXXXXXX} Dear
[Insurer]:
I am writing this letter in response to the above referenced denied claim to provide
clinical justification for [patients name]’s Impella® procedure.
Physician/Facility Free Text:
Establish the risk profile of the patient
Mention patient case history and condition prior to the procedure, if patient was a
surgical turndown
Coronary anatomy risk (RCA, LAD, triple vessel disease, etc.)
Establish the hemodynamic profile prior to Impella (this can be provided by the
physician)
Note any additional MCC’s and CC’s to support the need for hemodynamic support Note
if other