Free appeal letter 39
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Sample Appeal Letter from a Specialist
This sample is applicable to 32-35 wGA infants with risk factors

@[email protected]

@[email protected]
Dear @[email protected]
This letter is to appeal the denial of Synagis (palivizumab) therapy for @[email protected]
with denial reference of ***. Synagis is medically necessary for this patient and
is an FDA-approved product for the prophylaxis of severe respiratory syncytial
virus (RSV) disease in infants and children at high risk for severe RSV disease.
Patient history and diagnosis
@[email protected] is a @gestational [email protected] with additional risks of ***. For these
reasons he/she requires Synagis to reduce his/her risk of contracting RSV in
the upcoming RSV season.
Medical necessity of therapy
Synagis is indicated for the prevention of serious lower respiratory tract infection
caused by RSV in children with a history of prematurity (35 weeks gestational
age) Chronic lung disease, such as, bronchopulmonary dysplasia (BPD), and
hemodynamically significant heart disease. Synagis therapy has bee