SAMPLE APPEAL LETTER – VSL3 POUCHITIS INSURANCE COMPANY RE

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OFFICE OF EDUCATIONAL OUTREACH COLLEGE OF EDUCATION SAMPLE
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Sidney Kimmel Comprehensive Cancer Center @ Johns Hopkins Hospital


SAMPLE APPEAL LETTER – VSL#3 POUCHITIS


Insurance Company

RE:

DOB:

ID #

Pat Acct #


DATE


Dear Sir or Madam:


I am writing this letter in reference to my patient, Mr./Ms. Doe, who I follow for ileal pouchitis following total colectomy with ileal pouch anal anastomosis surgery for ulcerative colitis. I am requesting coverage for Visbiome®.


The probiotic formula studied in the references below was formerly known as VSL#3, but is now known as ‘De Simone Formulation’ which is sold under the brand Visbiome®.

 

Due to a history of antibiotic-responsive pouchitis, we have recommended that our patient take Visbiome® for prevention of recurrent pouchitis.  Multiple studies including randomized controlled trials published in high-impact gastroenterology journals have shown that the addition of Visbiome® following a course of antibiotics decreases the recurrence of pouchitis in patients with relapsing pouchitis and antibiotic-dependent pouchitis1,2,3. As prolonged antibiotic courses have been associated with Clostridioides difficile infection, and antibiotics-related side effects (tendinopathy and tendon rupture with fluoroquinolones, and neuropathy and dysgeusia with nitroimidazole antibiotics), using probiotics is a safer and effective approach. 

 

Based on the above data, I urge you to cover Visbiome® for the treatment of pouchitis.


Thank you for your attention and prompt approval.  Please do not hesitate to contact our office with questions or concerns regarding this correspondence.


Sincerely,



Dr.

Address

References:


  1. Gionchetti P, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology. 2000;119(2):305-9.

  2. Mimura et al. Once daily high dose probiotic therapy (VSL #3) for maintaining remission in recurrent or refractory pouchitis.  Gut. 2004;53:108-114. 

  3. Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology. 2003;124(5):1202-1209. Doi:10.1016/s0016-5085(03)00171-9

  4. Nguyen N, Zhang B, Holubar SD, Pardi DS, Singh S. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2019;5(5):CD001176. Published 2019 May 28. doi:10.1002/14651858.CD001176.pub4


 


Disclaimer: The sample appeal letters available to healthcare providers on the Crohn’s & Colitis Foundation’s website may include use of agents for conditions other than their FDA-approved indications. The Crohn’s & Colitis Foundation does not endorse the use of any specific medication or treatment, including any use which is outside the labeled indication. The Crohn’s & Colitis Foundation provides this resource for informational purposes only. The Crohn’s & Colitis Foundation, its agents, officers, employees, and volunteers shall not be liable for any claims, damages, or actions whatsoever which may arise for the use of this information. (Remove disclaimer prior to submission of recipient)




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