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Sample Insurance Physician Appeal Letter #1
The letter should be tailored to the patient.
Insurance Company Name
City, State, Zip code

Patient Name
Date of Birth:
Appeal Account #:

Dear Insurance Company:
I am appealing the decision and request immunoglobulin be approved for this patient.
Disease: Common Variable Immune Deficiency (279.06); severe recurrent infections (listed below), hypothyroidism, allergies
Clinical History:

Types of infections:
Severe recurrent sinopulmonary infections, but has been on chronic antibiotics for the past 11 months with partial benefit but
constant relapse.
Sinus x-rays demonstrated clear-cut pansinusitis with opacification, systemic antibiotics together with nasal irrigation gentamicin
and an empiric course of Diflucan.
Patient also had chronic bronchitis with copious mucus.

Hospitalizations & Surgeries: 2 (Sinus surgery & total thyroid removal)
Laboratory Studies:

After four doses of Prevnar and two doses of the pneumococcal