Note: This sample letter should be personalized to your own situation, such as whether you are having thyroid remnant ablation following your thyroid surgery, or are having follow-up testing. Follow-up testing may include a radioiodine whole-body scan or Thyroglobulin (Tg) testing, or both types of testing.
[Insert your Name and Address]
[Insert your Insurer’s Address]
Subscriber Name: [ (Insert name]
Subscriber ID: [Insert ID Number]
Patient Name [Insert name]
Dear [Insert name of insurance company’s medical director]:
I would like to request coverage approval for the administration of Thyrogen® (thyrotropin alfa for injection), which my physician has prescribed for me.
Thyrogen® is a drug first approved by the FDA in November 1998. It was developed for use as part of the procedures that detect the recurrence of differentiated thyroid cancer.
In addition, in December 2007 the FDA approved its use in combination with radioiodine to ablate, or destroy, the remaining thyroid tissue in patients who have had their cancerous thyroids removed.
I was diagnosed with well-differentiated thyroid cancer on (Insert date). (Also insert brief details regarding treatment following your diagnosis such as partial or total thyroidectomy, radioiodine therapy, hormone replacement therapy, diet restrictions, number of times you have withdrawn from thyroid hormone therapy for a whole-body scan or Thyroglobulin (Tg) testing).
Thyrogen® has been recommended by my physician so that I do not have to stop taking my thyroid hormone replacement therapy. Stopping taking thyroid hormone is connected with symptoms associated with hypothyroidism such as sluggishness, muscular aches and pains, dry skin, anxiety, loss of appetite, sensitivity to cold, weakness, fatigue, loss of concentration, mood swings, depression, and weight gain. These symptoms can be severe enough to result in missing work. I also am unable to drive during some of this time.
The injections of Thyrogen® will allow me to continue taking my thyroid hormone replacement and avoid thyroid hormone withdrawal. The effects of withdrawal are very unpleasant and limit the ability to function as I normally do on a daily basis. I am relieved that there is a product to help me during this difficult time.
Please send written verification of my insurance coverage for Thyrogen® to my physician as soon as possible. My [insert wording about what you will have ……remnant ablation….next whole body scan….Thyroglobulin test] is scheduled for [insert Date]. Due to the time sensitivity of this, any expedited coverage approval and notification will be greatly appreciated.
Thank you for your attention to this matter.
[nsert your name—in both print and with your signature]
cc: [Insert your physician’s name and address]
Last updated: December 23, 2007