Free appeal letter 38Free appeal letter 38
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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.
PATIENT INFORMATION
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)
Patient:
Jane Doe
ID:
XXX123456789
Provider:
Ulysses Grant, M.D.
Claim #:
111111
Date of service:
July 4, 2005
Original Claim:
$270.00
Date of EOB:
December 31, 2005
Explanation