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 (type) Multiple Sclerosis. 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: ____________________________________________________________________________________________________________________________________________.
The ability of heat to aggravate symptoms in patients with definitive MS is well-established.
Cooling studies as early as 1959 have revealed positive symptomatic outcomes for patients with MS. Cooling can result in objective clinical improvements in several functional systems of heat-sensitive MS patients, according to a clinical study performed by P.K. Coyle, M.D. and colleagues1. The effects of cooling reinstate energy in heat-blocked axons, allowing neural activity restoration, enabling remyelination to provide protection for axons from further degeneration; and potentially slowing the destructive progression of MS.
In a double-blind, randomized study to determine the effect of daily cooling garment use, 84 patients with definite MS received either high-dose or low-dose cooling for one hour per day for one month. The high-dose cooling group demonstrated a small but significant improvement in function and reported less fatigue on standardized, objective measures in comparison to the lower-dose group2.
Therefore, 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 hope this information is helpful to you and others, and encourages you to think about the beneficial outcome for (patient’s name) by (choose one: reconsidering/authorizing) (him/her) as a recipient of a cooling garment.
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)
1 Coyle P.K., Krupp L.B., Doscher C., et.al. Clinical and Immunological Effects of Cooling in Multiple Sclerosis. Neurology 1996; 10;1: 9–15.
2 Schwid SR, Petrie MD, Murray R, et. al., A randomized controlled study of the acute and chronic effects of cooling therapy for MS. Neurology, 2003 June 24; 60(12): 1955–60.
All prices are in USD.