Appeal / Preauthorization / Reimbursement Request
Today’s date ________________________________________
Plan Name/Number __________________________________
Plan Address _______________________________________
To whom it may concern:
This is a request for (choose one: appeal of your denial, pre-authorization, reimbursement) of a cooling vest for my patient, (patient name), who lives with (state the medical condition). I prescribed this specialized garment to help manage and/or relieve the patient of the various symptoms induced or exacerbated by warm environments, including ____________________________________________________________________________________________________________________________.
(Patient name) has sought medical care due to heat-related symptoms on the following occasions: ____________________________________________________________________________________________________________________________________________.
After careful consideration of (patient’s name)’s needs, functional capability and symptoms including (fill in specific details of relevant symptomatology and personal complaints), it is my conclusion that a cooling device would assist in improving (patient’s name)’s overall quality of life as well as functional abilities.
I look forward to, and appreciate, your prompt response in this pressing matter.
Very Truly Yours,
(Physician name and signature)
(Physician contact information)
CC: (patient’s name)
(patient contact information)