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patient Sample Letter of Appeal Sample Letter of arthritis



[Contact] usually the medical director
[Name of Health Insurance Company]
[City, State, ZIP Code]

Insured: [Name]
Policy Number: [Number]
Group Number: [Number]

Dear [Name of Contact]:

This letter serves as a request for reconsideration of payment for Kineret(R provided to me on [date of
service]. Kineret® is a self-injected medication for the treatment of rheumatoid arthritis.

You have indicated that Kineret(R is not covered by [insurance company name] because [denial reasons]. I
feel that this denial is not appropriate. My physician, [physician name and title], prescribed this medication
to me because [he/she] believes it is medically necessary to treat my condition of rheumatoid arthritis.

[Include detail specific to your rheumatoid arthritis medical history, such as: (1) your diagnosis, (2)
length of time that you have been diagnosed with rheumatoid arthritis, (3) different therapies that you
have tried and that have failed, (4) any other pertinent medical history that your physician has in your
medical file and recommends that you include.]

Kineret (anakinra) is indicated for the reduction in signs and symptoms and slowing the progression of
structural damage in moderately to severely active rheumatoid arthritis, in patients 18 years of age or older
who have failed 1 or more disease-modifying antirheumatic drugs (DMARDs). Kineret  can be used alone
or in combination with DMARDs other than tumor necrosis factor (TNF) blocking agents.

There was a risk of serious infections (2% in Kineret patients vs  1% in placebo patients) in the clinical
trials. Although Kineret should be discontinued if you develop an infection, most often you can continue
taking Kineret after your infection resolves. You should not use Kineret  if you are taking TNF-blocking
agents such as etanercept, adalimumab, or infliximab, unless your physician has told you to do so. If you
use Kineret with etanercept, adalimumab, or infliximab, you may increase your risk of getting a serious
infection. The most common side effect was a reaction at the site of injection, usually mild, characterized
by redness, swelling, and pain.

Based on the above information, I am requesting that you reconsider payment for Kineret (R. Thank you in
advance for your immediate attention to this request. If you require further information, please call me at
[telephone number].


[Patient Name]

Attachments [original claim form, copy of denial or explanation of benefits, additional supporting
documents received from your physician]

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