COMPOSING A LETTER OF MEDICAL NECESSITY
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This guide is for informational purposes only. It is not intended to provide reimbursement or legal advice. Individual health plans’ policies concerning reimbursement are complex and frequently revised. Therefore, please contact third-party payers for specific information on coverage policies. For more information, please call 1-844-4OTEZLA (1-844-468-3952).
Many plans require a Letter of Medical Necessity to accompany an Appeal Letter supporting the choice of Otezla® (apremilast) over other agents that are on the formulary. The purpose of the letter is to explain the rationale for the drug.* The following resource provides information to help in the process of writing a Letter of Medical Necessity, including the checklist below and a sample letter.
CHECKLIST
This checklist can help ensure all relevant information is included in the Letter of Medical Necessity:
Patient’s name, policy number, and date of birth
Support for recommending Otezla (patient history, diagnosis, and current condition; include relevant medical records and history of infections, allergies, and existing comorbidities)
Documentation of severity of condition (include photos)
List of previous therapies and duration of treatment, including explanation of why each therapy was discontinued
Explanation of why formulary-preferred agents are not appropriate and clinical support for your recommendation (this clinical trial data can be from the Otezla package insert)
*For Medicare beneficiaries, there are specific requirements that need to be met for the HCP to be considered a legal representative of the patient in an appeal. For additional information, please visit: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf.
SAMPLE LETTER OF MEDICAL NECESSITY
Step 1.
Step 2.
Step 3.
Step 1.
Include the patient information
Step 2.
Provide the information relevant to the
primary diagnosis
Step 3.
Describe the patient history and current condition (include copies of relevant medical records)
Step 4.
Step 5.
Step 6.
Step 7.
Step 8.
Step 9.
Step 4.
Outline the severity of symptoms (include pictures, as appropriate)
Step 5.
List previous therapies
Step 6.
Include patient’s clinical response to prior therapy
Step 7.
Include your recommendation here. Include clinical rationale and your professional opinion of the patient’s likely prognosis or disease
Step 8.
Provide a phone number should any additional information be required
Step 9.
Please sign your name to complete the letter
PLEASE BE SURE THAT ALL RELEVANT SECTIONS OF THE LETTER
ARE COMPLETELY AND CORRECTLY FILLED OUT
OTEZLA LETTER OF MEDICAL NECESSITY
Medical director
Insurance company
Address line 1
Address line 2
Address line 3
Address line 4
Patient name
Policy number
Date of birth
PHYSICIAN’S REQUEST FOR REVIEW:
Peer-to-peer review requested (same or like specialty)
I am writing to provide additional information to support my request for the treatment of
with Otezla® (apremilast) for Primary
L40.50 (Arthropathic psoriasis,
unspecified)
L40.51 (Distal interphalangeal
psoriatic arthropathy)
L40.52 (Psoriatic arthritis mutilans)
L40.53 (Psoriatic spondylitis)
L40.59 (Other psoriatic arthropathy)
L40.0
(Psoriasis vulgaris)
%BSA Affected
L40.8
(Other psoriasis)
%BSA Affected
L40.9
(Psoriasis, unspecified)
%BSA Affected
In brief, treating
with Otezla is medically appropriate and necessary and should be covered and reimbursed. Below, this letter outlines the medical history, prognosis, and treatment rationale for
SUMMARY OF PATIENT HISTORY:
[Note: Exercise your medical judgment and discretion when providing a diagnosis and characterization of the patient’s medical condition.]
Patient’s history, diagnosis, and current condition:
Brief description of the patient’s recent symptoms and conditions (including BSA% for Plaque Psoriasis patients):
Previous therapies the patient has undergone for the symptoms associated with:
Patient’s response to previous therapies. If patient has discontinued, please include reason for discontinuation:
Summary of your professional opinion and the patient’s potential prognosis with treatment with Otezla® (apremilast):
Please call my office at
if I can provide you with any additional information to approve my request. I look forward to receiving your timely response and approval of this request.
Sincerely,
