Free appeal letter 36
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Sample Appeal Letter for Payment of CPT 90714
[Insurer Name and Address]

Policy Number:
Group Number:
Claim Number and Date of Service:

Please consider this letter a formal request for reconsideration of [inadequate or denied] payment for the
administration of DECAVAC®, Tetanus and Diphtheria Toxoids Adsorbed For Adult Use (Td vaccine), to
[patient’s name] on [date of service] by [name of physician].
The Advisory Committee on Immunization Practices (ACIP) recommends the use of Td vaccines such as

Persons 7 years of age and older who have not been immunized previously against tetanus and
diphtheria as a primary immunization series of 3 0.5mL doses 1
Use as a routine booster every 10 years throughout life for persons 7 years of age or older who
have received a primary series of tetanus and diphtheria toxoid-containing vaccine 1
Wound care in persons who have not received a tetanus toxoid-containing preparation with