SAMPLE LETTER OF APPEAL

Date Name of Medical Director Insurance Company Address Re: (Patients Name) Diagnosis: Group: Policy Number: Dear Medical Director:
This letter serves as a request for formal appeal of denied claim (insert claim #) for (insert patient name), policy number (insert policy #). The denied claim represents charges for immunization with Menveo (Meningococcal [Groups A, C, Y and W-135] Oligosaccharide Diphtheria CRM197 Conjugate Vaccine). Menveo is a vaccine indicated for active immunization to prevent invasive meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135. Menveo is approved for use in persons 2 to 55 years of age. Menveo does not prevent N. meningitidis serogroup B infections. Meningococcal disease is a serious and potentially life-threatening infection caused by the bacterium N. meningitidis. (Insert current ACIP recommendation.) I believe this denial of coverage of Menveo for (insert patient name) was in error because (insert reason for appealing the denial). As such, it should be a covered and reimbursed service under the patients plan. To demonstrate the effectiveness of Menveo I have enclosed product prescribing information. This information details the safety and efficacy of Menveo. After reviewing this material, I hope you will agree that Menveo should be available and reimbursable to members of your health plan. I request that (insert health plan) adjudicate and pay this claim for Menveo. I look forward to a positive and timely resolution of this claim and would request that you update your coverage policy to ensure that future claims are paid appropriately. If you have any questions regarding Menveo or the materials contained in this package, please do not hesitate to call.

Thank you for your time and consideration. Sincerely, (Physicians Signature), MD

04/11

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