This is sample text for a letter from your health care provider to show your medical need for a procedure, visit or medication. Edit and personalize the bracketed sections with your information. Ask your PH team to put on your clinic or PH center’s letterhead.
[Date]
[Insurance company name]
[Address]
[Phone/Fax]
Re: [Patient name, date of birth]
[Member ID]
Dear Claims Representative:
I am writing on behalf of my patient, [patient name and policy number], to request that [health insurance company name] approve coverage for [explanation of therapy, treatment, service, etc.] in relation to their pulmonary hypertension diagnosis.
This letter provides information regarding this patient’s medical history, diagnosis and treatment plan and confirms the medical necessity and appropriateness of this prescribed treatment.
Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary artery. PH is grouped into five clinical classifications:
Group 1 PH: Pulmonary arterial hypertension
Group 2 PH: PH due to left heart disease
Group 3 PH: PH due to chronic lung disease and/or hypoxia
Group 4 PH: Chronic thromboembolic pulmonary hypertension
Group 5 PH: PH with unclear, multifactorial mechanisms
When PAH occurs in the absence of a known cause, it is referred to as idiopathic pulmonary arterial hypertension. Idiopathic PAH is extremely rare, occurring in about one person per million population per year.
PAH also can occur in association with other diseases and exposures, including historical anorexigen exposure, methamphetamine use, collagen vascular diseases, HIV infection, portal hypertension and congenital heart diseases.
PAH is an incurable, progressive illness with FDA-approved oral, inhaled, and parenteral targeted treatment options. [Name of treatment] has been shown to significantly improve prognosis.
Patient’s History and Diagnosis
[Insert information about patient’s history with the disease, including previous treatments and results.]
Based on the above information, I would appreciate your reconsideration of coverage for these submitted charges. [Name of treatment] is medically necessary to treat this patient’s [diagnosis]. If you require any additional information, please contact me at [physician’s contact information].
Sincerely,
[Provider’s name]