RESOURCE FOR APPEALING COVERAGE
- Reason for request
- Reason for denial
- Rationale to address each reason for denial, including relevant clinical rationale where applicable
- Relevant overall patient medical history and current condition
- Relevant cost information (if known)
- Summary of your professional opinion of likely outcome with the treatment
- Restatement of request for approval
- Third-party payers may require physicians to submit documentation to support prescription coverage, including medical justification for the prescribed treatment. Provided for your use is relevant clinical rationale for the specific needs of your patient.
- The clinical rationale represents just one component of what is commonly called an “appeal” or “Letter of Medical Necessity.” This tool is intended to complement any existing letter or form you may currently use.
- Should you not have an existing letter/form that you use, please click on “generate full-form letter” and follow the appropriate prompts.
Please note: The guidance presented here is for informational purposes only and is not intended to provide reimbursement or legal advice. AbbVie does not guarantee that the use of any information provided will result in coverage or payment by any third-party payer. You are responsible for the submission based on your clinical judgment. This information is provided for use by United States healthcare professionals only. It is not intended for patients.