ࡱ > 0 2 / ] bjbj11 : [,\[,\ r r $ " 6 6 6 6 6 y { { { { { { $ V 6 6 6 6 y y 6 p?{ : e 0 p | y p r > : <
>
Re: Expedited appeal of denial of coverage for <>
(DOB: xxx, SSN: ###, Tel: xxx)
UHC #: xxx
Group#: xxx
Company: xxx
File ID: xxx
<>
To Whom It May Concern:
I am writing this letter on behalf of my patient, xxx (DOB: xxx, ID: xxx, Group# xxx), to request coverage for imatinib (Gleevec ) for the treatment of sclerotic chronic graft versus host disease.
<> is a x y/o woman..describe case.
Two separate European studies have suggested that imatinib is able to reverse the fibrosis associated with sclerotic chronic GVHD that has been refractory to multiple agents. A prospective study by the Italians (GITMO) in 19 patients with refractory chronic GVHD showed an overall response rate to imatinib at 6 months of 79% (Olivieri et al. Blood, Vol 114, No. 3, 709-718). A retrospective study by the French in 14 similar patients treated with imatinib showed an overall response rate of 50% (Magro et. al., Blood, Vol 114, No. 3, 719-722). Our own experience based on a prospective study done with Stanford, as well as our experience in subsequent non-study patients is that at least half the patients with sclerotic chronic GVHD have a clinically meaningful response.
I appreciate your time and consideration of this matter and do hope that you will allow <<>> to be treated with imatinib. Please expedite your evaluation so that the patient may begin therapy as soon as possible as her sclerosis appears to be progressing. If you would like to discuss this case directly, please call me at (xxx) xxx-xxxx.
Sincerely,
<>
Attachments:
Olivieri et al. Blood, Vol 114, No. 3, 709-718
Magro et. al., Blood, Vol 114, No. 3, 719-722
> I Q T [ ^ e h j q r u v ~ Խ{d{dMM -hz h? CJ OJ ^J aJ fH q
-hz h8v CJ OJ ^J aJ fH q
'hTK CJ OJ ^J aJ fH q
-hz h) CJ OJ ^J aJ fH q
-hz hk_ CJ OJ ^J aJ fH q
-hz h{) CJ OJ ^J aJ fH q
-hz hu CJ OJ ^J aJ fH q
'h6s CJ OJ ^J aJ fH q
J j v + ,
/ p@P !$`' gdl]
/ p@P !$`' gd)
gd) gd) $ + c m Սvivivi\vOv\vv hz hl] OJ QJ ^J hz h8v OJ QJ ^J hz h OJ QJ ^J hz h{) OJ QJ ^J hTK OJ QJ ^J ,hz h{) OJ QJ ]^J fH q
h6s OJ QJ ^J #hTK OJ QJ ^J fH q
)hz hk_ OJ QJ ^J fH q
)hz h{) OJ QJ ^J fH q
)hz h OJ QJ ^J fH q
.
E
= L Y Z e g o 9
%
2
P
`
p
( 8 : O P 淢{{{qdZ hTK OJ QJ ^J hz h#w OJ QJ ^J h: OJ QJ ^J )hz hd OJ QJ ^J fH q
#h6s OJ QJ ^J fH q
)hz hl] OJ QJ ^J fH q
)hz h{) OJ QJ ^J fH q
hz h 8 OJ QJ ^J hz h OJ QJ ^J hz h{) OJ QJ ^J hz hV45 OJ QJ ^J ", 7 8 9 : P Q _ `
/ p@P !$`' gd)
gd)
P hz h6 OJ QJ ^J mHsH hz h6 OJ QJ ^J 8 P :p{) / =!"#F$% Dp s 2 0 @ P ` p 2 ( 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 8 X V ~ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ 0 @ _HmH nH sH tH @ ` @ N o r m a l CJ _HaJ mH sH tH D A D D e f a u l t P a r a g r a p h F o n t V i V T a b l e N o r m a l :V 4 4
l a ( k ( N o L i s t Z o Z
G [ N o r m a l ] 7$ 8$ H$ $ CJ OJ QJ ^J _HaJ mH sH tH e@
G H T M L P r e f o r m a t t e d 7
2 (
Px4 #\'*.25@9 B*CJ OJ PJ ^J aJ ph P P B a l l o o n T e x t CJ OJ QJ aJ mH sH tH J /!J B a l l o o n T e x t C h a r CJ OJ QJ aJ B ' 1B V45 C o m m e n t R e f e r e n c e CJ aJ <