Free appeal letter 43Free appeal letter 43Free appeal letter 43
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Example #6
Sample Appeal Letter for Claims Denial
This letter provides an example of the types of information that may be provided
when appealing a claims denial from a patient’s health plan for EYLEA®
(aflibercept) Injection treatment.
Use of the information in this letter does not guarantee that the health plan will
provide reimbursement for EYLEA and is not intended to be a substitute for or an
influence on the independent medical judgment of the physician.
A copy of the full Prescribing Information for EYLEA is available for download on
www.EYLEA.com.
Some Key Reminders:
• Use an appeal letter when reimbursement for a claim is underpaid or denied
• The appeal letter should come from a treating physician and should be signed
by both the physician and patient
• Refer to the ICD-10 Coding Guidelines here regarding certain codes that may
be applicable to the patient’s diagnosis

© 2017, Regeneron Pharmaceuticals, Inc.
US-LEA-13741

01/17

All rights reserved

EXAMPLE
Re: [Patient full