Letter of Medical Necessity (Allergy & Immunology)

[Physician Letterhead] Attn: Dr. John Smith HealthFirst Insurance 123 Health Lane Springfield, IL, 62701 RE: Emily Johnson Date of Birth: 15 March 1985 Policy Number: HF123456789 Claim Number: CL987654321 Request: Authorization for treatment with Xolair Diagnosis: Chronic Idiopathic Urticaria (L50.1) Dosage: 300 mg every 4 weeks 1 November 2024 Dear Dr. Smith, I am writing on behalf of my patient, Emily Johnson, to document the medical necessity of Xolair, which is indicated for the treatment of Chronic Idiopathic Urticaria. This request is supported by the following information: Summary of Patient’s History • Diagnosis: Chronic Idiopathic Urticaria, diagnosed on 10 January 2023 • Laboratory results: Elevated IgE levels, 15 January 2023 • Current medical condition: Persistent hives and angioedema despite antihistamine therapy • Previous and current treatments/therapies: High-dose antihistamines, corticosteroids • Patient’s response to those treatments/therapies: Partial response to antihistamines, intolerable side effects from corticosteroids • Discontinued corticosteroids due to lack of tolerability Rationale for Treatment Considering the patient’s medical history, current medical condition, and the supporting uses of Xolair, I believe treatment with Xolair at this time is warranted, appropriate, and medically necessary for this patient. The following documentation is enclosed: • Xolair full Prescribing Information • Medical literature regarding the use of Xolair for Chronic Idiopathic Urticaria; ICD-10 Code L50.1 • Relevant clinical documentation such as history and physical, progress notes, treatment history, and outcomes, if supportive Please call my office at (555) 123-4567 if you require any additional information or documentation. I look forward to your timely response. Sincerely, Dr. Sarah Thompson Provider Number: 123456 Enclosures