The MAGIC Foundation



SAMPLE LETTER OF APPEAL FOR AFFECTED ADULTS

Date Sent

Appeal Company

Address

City, State, Zip

I am composing this letter in regards to the denial of Growth Hormone Therapy. After having reviewed the adverse determination, our organization strongly disagrees with CVS Caremark’s decision. Our explanation is outlined below.

1. I am a thirty-eight-year-old man/woman with a diagnosis of Adult Growth Hormone Deficiency.

2. CVS Caremark has denied the request for treatment coverage based on CVS Caremark’s opinion that the request lacks medical necessity due to certain criteria being unmet. Specifically, CVS Caremark requires __ pituitary hormone deficiencies and IGF-1 levels that are below the normal range.

3. CVS Caremark’s criterion is not consistent with criteria established by national endocrine societies.

4. Consensus guidelines state that one failed stimulation test is sufficient to diagnose Adult Growth Hormone Deficiency. Please see enclosed consensus statement.

5. I have failed the stimulation testing, demonstrating that as diagnosed by my physician (DR NAME), I am Growth Hormone Deficient. This serves as biochemical evidence that he is Growth Hormone Deficient.

6. IGF-1 levels were ?? ng/mL, which is below the normal range of (106-368)use proper lab notes.

7. The established standard of care for Adult Growth Hormone Deficiency is to treat with growth hormone therapy. Growth hormone is FDA approved and recommended by the medical community for AGHD.

8. Medically Necessary is defined as: a service required to diagnose or to treat an illness or injury. To be Medically Necessary, the service must be; performed or prescribed by a doctor, be consistent with the diagnosis and treatment of your condition, be in accordance with standards of good medical practice, not be for the convenience of the patient or his doctor and is provided in the most appropriate setting.

9. The request for growth hormone treatment meets the definition of Medically Necessary, in its entirety.

10. Endocrinologist, Dr. _________, has determined that growth hormone therapy is the appropriate treatment for my condition.

For your reference, I have enclosed; IGF results, stimulation test results and supporting literature.

My ultimate goal is to ensure that I have the opportunity to live a productive and healthy life. We hope that you share the same vision.

If you need to contact me, I can be reached at (708) 383-0808. Thank you in advance for your consideration in this matter.

Regards,

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