Template Letters | Request to Insurer for In-Network Payment
This letter is only an example. Please edit the letter to suit your needs and replace [bold]sections with the appropriate information. The patient should keep an original signed copy for their records.
[PRINT ON MEDICAL CENTER OR INSTITUTION LETTERHEAD]
[DATE]
Re: [PATIENT NAME, DOB]
To Whom It May Concern:
This letter is to request In-Network payment for [PATIENT NAME]to receive appropriate testing, management and monitoring of a complicated condition called pulmonary hypertension.
Pulmonary hypertension has several causes and is difficult to diagnose. When Pulmonary arterial hypertension (PAH) is identified, it is a severe and life threatening disease in which the blood pressure in the pulmonary artery rises far above normal because of an increased resistance to blood flowing through the smallest blood vessels in the lungs. This increased resistance creates a strain on the heart, and eventually leads to heart failure and death without treatment. Untreated, the average length of survival after diagnosis is less than three years. Symptoms of pulmonary hypertension include exertional shortness of breath, fatigue, swelling of the lower extremities and abdomen, chest pain, dizziness, and as the disease progresses, loss of consciousness.
A systematic sequence of tests is done to identify all conditions that may contribute to the high blood pressure in the lungs. However, the gold standard for the diagnosis of pulmonary arterial hypertension is a right heart catheterization that includes acute vasodilator testing and an assessment of all pertinent hemodynamic parameters. Our center utilizes [VASODILATOR AGENT] for this testing. Results determine the severity of disease and help guide decisions regarding appropriate therapy. This approach is recommended by the American College of Chest Physicians (ACCP), found in McGoon M, et al. Screening, Early Detection, and Diagnosis of Pulmonary Arterial Hypertension: ACCP Evidence-Based Clinical Practice Guidelines. Chest 2004;126: 14S-34S.
While [PATIENT NAME]underwent a right heart catheterization locally, the study was incomplete because it did not include a vasodilator challenge. [PATIENT NAME]has not received an optimal evaluation of [HIS/HER] pulmonary hypertension, and it is for that reason, that I am urging you to reconsider your decision to deny coverage for a repeat right heart catheterization with vasodilator testing at our institution. Additional testing that may be necessary to monitor response to therapy include[DESCRIBE ADDITIONAL TESTS AS INDICATED].
Medical therapy for Pulmonary Arterial Hypertension is complicated; therefore, patients should be followed by clinicians who have the necessary experience in treating this disease. These therapies require close monitoring because of multiple side effects and can be dangerous to patients if not used appropriately. Moreover, because of the rapidly progressive nature of the disease, the clinical response to these therapies must be followed very closely.
Because pulmonary hypertension needs to be followed in a specialized center, I would ask that you, the insurer, allow [PATIENT NAME]to be further evaluated and managed at [PH CENTER NAME], and that you cover these necessary medical expenses at an in-network rate of reimbursement (100%).
If you have any questions regarding this patient, the disease, or the therapies that are available for the treatment of pulmonary hypertension, please do not hesitate to contact [CONTACT INFORMATION].
Sincerely,
[PHYSICIAN NAME], [DATE]
[SIGNATURE]
[PRINT NAME]
[ADDRESS]
[PHONE NUMBER][FAX NUMBER]