SAMPLE PHYSICIAN APPEAL LETTER
FOR PROMETHEUS™ Thiopurine Metabolites
(Please edit appropriately based on your patient’s medical history and treatment experience.)
John Smith, Medical Director
Red Cross Red Shield
P.O. Box 12345
Los Angeles, CA 90060
Dear Dr. Smith:
I am writing to appeal your decision about medical coverage for the PROMETHEUS™ Thiopurine Metabolites serology
test for my patient, Jane Doe. I am Ms. Doe’s gastroenterologist practicing at Sunnyvale Community Hospital in San
Diego, CA. I respectfully request that you reconsider your decision based on the medical necessity of this test.
My patient has a history of inflammatory bowel disease and is taking thiopurine medication.
(List information relevant to the patient’s symptoms, treatment and test results if applicable)
Ulysses Grant, M.D.
Date of service:
July 4, 2005
Date of EOB:
December 31, 2005