An effective letter adheres to a few key points. “The most important thing is language. Insurance companies respond to very specific phrasing,” says Kiara DeWitt, RN, a pediatric neurology nurse at Cook Children’s Medical Center in Fort Worth, Texas, whose patient advocacy efforts include helping them decode insurance denials and navigate billing misfires.
“If your provider says, ‘patient needs X,’ that is a maybe. If they say, ‘documented failure on formulary alternative,’ the odds go way up,” she says. “If they add ‘evidence of escalation protocol failure’ or ‘risk of irreversible condition progression,’ that kicks it up again. These details matter. Get clinical. Get exact. Avoid emotion. Speak their language.”
Some insurance plans allow formulary exceptions to be submitted online. Check your health plan’s website to see if you can file electronically. If you’re denied approval, the Patient Advocate Foundation advises calling your health plan about the denial. Every plan is required to have an appeals process, so ask what your timeline is for submission. You can file the appeal on your own, ask your doctor for assistance, or seek out a patient advocate to help.