ATTN Appeals Department

ATTN Appeals Department Street Address City, State, Zip

To Whom It May Concern: RE: Member ID#______DOB 9/9/99

This is an appeal of your recent denial for coverage of XXXX 1mg SQ every 2 weeks.

The above-named individual has been under my care since March 9999. He has a diagnosis of Crohn’s disease of the large intestine as well as perianal fistulizing disease (K50.113).

Mr. was first diagnosed with Crohn's colitis in 20XX. Since diagnosis, treatment regimens in the past have included; drug1, drug2, drug3, drug3, and drug4. Due to these ongoing medication failures and active clinical symptoms (abdominal pain, rectal bleeding), colonoscopy was performed on 1/9999 showing ______.

Recently we were able to get him approved for XXXX and he has now taken the induction dose and first maintenance dose but has continued to have worsening symptoms as he tapered off of prednisone. Therefore, it was recommended that he increase the maintenance dose of XXXX to 1mg SQ every 2 weeks. When this request was made, a denial for the medication itself was sent although this had been approved and covered up until this point.

Mr. has had severe colitis even while on multiple therapy regimens to manage his Crohn’s disease and there are no other FDA-approved options at this point for him. XXXX was chosen as this medication has been shown to be effective in colonic inflammation which is the location of the majority of his disease activity. The only other alternative in this setting would be another course of prednisone, which due to the potential systemic short- and long-term side effects, would not be preferred in this case. If prednisone is needed due to the denial of XXXX coverage, this may add additional health concerns such as osteoporosis, cataracts, and diabetes for my patient. These conditions would add considerable expense to his needs on a chronic basis.

If we are unable to proceed with the XXXX treatment which has already been initiated due to previous approval, Mr. will likely have a progression of disease and may require a surgical intervention which would no doubt add considerable cost to his treatment.

We would like to continue with XXXX 1mg SQ every 2weeks IMMEDIATELY. If I can provide any additional information or you need additional clinical records, please do not hesitate to contact me.

Sincerely.

MD Signature NAME Credentials