Appeal Letter for Prior Authorization Denial

Michael Thompson
456 Oak Lane
Springfield, Illinois, 62704
217-555-0198
November 5, 2024

To:
GreatCoverage Health Insurance
8900 Health Plaza
Springfield, Illinois, 62712
Attn: Appeals Department

Subject: Appeal for Prior Authorization Denial – Policy Number: GH5678J

Dear Appeals Department,

I am reaching out to formally challenge the recent denial of the prior authorization request for the medication Enzalutamide for my wife, Sarah Thompson, who is insured under my policy (GH5678J). This denial, received on October 28, 2024, overlooks critical aspects of her medical needs and the explicit recommendation of her oncologist, Dr. Linda Wei.

Sarah has been battling metastatic breast cancer for over two years. Despite multiple lines of treatment, including chemotherapy and hormonal therapy, her disease has progressed. Dr. Wei has recommended Enzalutamide as an essential next step in Sarah’s treatment plan, citing its proven efficacy in similar cases. Unfortunately, your decision to deny coverage for this medication disregards its potential to significantly improve Sarah’s quality of life and manage her disease more effectively.

Enclosed with this letter, you will find a detailed explanation from Dr. Wei regarding the necessity of Enzalutamide in Sarah’s treatment regimen. The letter outlines why alternative treatments are not suitable for Sarah’s condition and provides evidence from recent studies supporting Enzalutamide’s use in her case. Additionally, I have included Sarah’s medical records highlighting her treatment history and the progression of her condition.

This appeal is not just a request for reconsideration but a plea for understanding the gravity of Sarah’s situation. Denying her the medication that offers a chance for stabilization and improved well-being could have dire consequences on her health.

Attached Documents:

Letter from Dr. Linda Wei detailing the medical necessity of Enzalutamide
Sarah Thompson’s recent medical records and treatment history
Prior correspondence regarding this authorization request
I am prepared to provide any further information needed and can be reached at 217-555-0198. We hope for a swift and favorable review of this appeal, acknowledging the critical nature of the requested medication in Sarah’s ongoing battle with cancer.

Thank you for your prompt attention to this urgent matter. We await your reconsidered decision with hopeful anticipation.

Sincerely,

Michael Thompson
Michael Thompson (for Sarah Thompson, patient)