Sample letter to insurance company on behalf of patient

You may copy or print this letter to use as a model. Note: This letter is only an example. Please edit the letter to suit your needs. 


Today's date 

Name of medical director
Name of insurance company
Street address
City, State ZIP code 

Dear Name of medical director,
I am contacting you on behalf of my patient, Name of patient (Insurance ID #). Name of insurance company has denied his/her claim for name of therapy/drug for his/her (form of) Epidermolysis Bullosa. Please consider this letter a formal, written appeal of your denial of this medically necessary therapy. 

EB-Epidermolysis Bullosa, is a genetic disease where the skin's fragility causes serious wounds all over the body, and there is no cure. Although EB reveals itself on the skin, there is also a significant negative effect on daily functioning associated with this disease. EB patients have esophageal problems, hands web and contract and infection is on-going concern. Epidermolysis Bullosa is a lethal condition, especially with poor treatment of wounds. Without proper treatment, EB is physically and emotionally devastating, preventing the carrying out of most normal activities, diminishing life expectancy. 

In view of Name of patient's signs, symptoms and history, I feel therapy/drug is medically necessary…. Explain the benefit/efficacy of the therapy/drug to specific patient and patient's history. 

If you have any further questions regarding this patient, please do not hesitate to contact me. 

Sincerely, 

Physician name
Physician address
City, State ZIP code
Phone number 

CC: State Insurance Commission
Name of patient
Epidermolysis Bullosa Action Network