To

[Insurance Company Name]

[Address]

[City, State, Zip Code]

Subject: Appeal for Medication Denial - Policy Number: F01

I am writing to appeal against the denial of coverage of IVIG treatment prescribed for Mr. X under Policy Number: F01. 

Mr. X suffers from a severe inflammatory muscle disease, specifically necrotizing autoimmune myopathy related to HMGCR-ab, statin-associated. As his healthcare provider at Henry Ford Health, I have carefully evaluated and prescribed IVIG infusions as a crucial component of his treatment regimen with the hope to produce a good outcome.  I am deeply concerned about the denial of this necessary immunomodulatory therapy for his muscle disease. 

Despite his recent hospitalization due to weakness in his limbs resulting in recurrent falls and rhabdomyolysis, Mr. X has exhibited only partial improvement with high-dose prednisone, which by itself is not considered standard care for his condition.  Furthermore, attempts to taper the prednisone have resulted in symptom relapse, severely limiting his mobility and impacting his ability to perform his occupational duties as an electrical inspector.  Prednisone monotherapy is not a treatment choice in this or other autoimmune inflammatory conditions.  It requires other immunosuppressants or immunomodulatory agents such as IVIG. 

It is important to emphasize that Mr. X medical history includes significant comorbidities such as diabetes mellitus, hyperlipidemia, elevated liver enzymes, and hypertension, which pose challenges in sustaining high-dose prednisone and increases the risk of adverse effects.  He cannot take immunosuppressants such as methotrexate, azathioprine, or mycophenolate mofetil due to significant delay due to their therapeutic lag and toxicities which will impair him further. 

IVIG has been identified as a medically necessary and evidence-based intervention for his specific condition, supported by recent research in the Journal of Neuromuscular Diseases (Mohassel P, Mammen AL, 2018) and the Journal of Clinical Rheumatology (Kocoloski, A, Martinez S, et al., March 2022). Denying coverage for IVIG not only endangers Mr. X's health but also hinders the recommended treatment that could significantly impact his long-term prognosis and quality of life.

Enclosed with this appeal, you will find comprehensive medical documentation highlighting the efficacy of IVIG in treating necrotizing autoimmune myopathy, especially in cases like Mr. X's, where other conventional therapies pose risks or have proven ineffective.

 Mr. X works as an construction inspector and his job entails climbing ladders, going up and down stairwells which he is currently unable to perform as result of persistent weakness accrued by the inflammatory muscle disease.  I am concerned without proper treatment of his condition he is at a risk of injury from falling.

I earnestly urge you to reconsider your decision and provide coverage for IVIG, understanding its critical role in ensuring the well-being and optimal care of Mr. X.  An expedited review of this appeal is crucial to prevent any further deterioration in his health and to mitigate the risk of potential injury due to his weakened state.

Thank you for your time and consideration.  I am hopeful for a compassionate and favorable resolution that prioritizes the health and care of my patient, Mr. XxX.

Please feel free to contact me at 313.900.2377 or ajowkar1@hfhs.org if further information or clarification is required.

Sincerely,

Abbas Jowkar, MD

Neuromuscular and Electrodiagnostic Medicine

ABPN Board Certified in Neurology

ABPN Board Certified in Clinical Neurophysiology

ABPN Board Certified in Neuromuscular Medicine

ABEM Board Certified in Electrodiagnostic Medicine

Henry Ford Health

K-11

2799 West Grand Boulevard

Detroit, MI 48202

ajowkar1@hfhs.org

Phone: 313.916.2585

Fax: 313.916.3014

References

Mohassel P, Mammen AL.  Anti-HMGCR myopathy. Journal of Neuromuscular Diseases 5 (2018) 11–20

Kocoloski, A, Martinez S, et. al.  Role of Intravenous Immunoglobulin in Necrotizing Autoimmune Myopathy. JCR: Journal of Clinical Rheumatology • Volume 28, Number 2, March 2022