[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-177786-105":53,"doc-detail-177786-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","guidance-on-completing-a-letter-of-appeal-for-entyvio-sample-letter-of-appeal","Guidance on Completing a Letter of Appeal for ENTYVIO - Sample Letter of Appeal","","Template guidance for completing a Letter of Appeal seeking reconsideration of an insurance denial related to ENTYVIO treatment. The material explains how to customize the physician letter with patient-specific diagnosis, medical history, prior treatments, and supporting documents. It includes an example structure covering denial details, medical necessity rationale for Crohn’s disease or ulcerative colitis, summary of the requested level of authorization, contact information, and an enclosure checklist to strengthen the appeal.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/guidance-on-completing-a-letter-of-appeal-for-entyvio-sample-letter-of-appeal/177786/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/guidance-on-completing-a-letter-of-appeal-for-entyvio-sample-letter-of-appeal/177786.png","ImageObject",442,249,{"name":88,"@type":89},"Eliana","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-20","2026-09-02",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information should be gathered before completing the Letter of Appeal for ENTYVIO?","Question",{"text":109,"@type":110},"Collect the patient’s medical diagnosis and history, then attach supporting documents requested by the plan in the denial letter.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What key elements should the sample appeal letter include?",{"text":114,"@type":110},"Include physician letterhead details, denial reason(s), the medically necessary treatment basis for ENTYVIO, and a section summarizing diagnosis and relevant clinical history.",{"name":116,"@type":107,"acceptedAnswer":117},"How should the appeal be submitted to the health plan?",{"text":118,"@type":110},"Submit the revised Letter of Appeal together with the prior authorization form so the insurer has a complete picture of the patient’s medical need.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},177786,1788329166,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},4398048949847,"https://ap-avatar.wpscdn.com/avatar/400002536579ef2da7f?_k=1778318612642679267","Guidance on Completing a Letter of Appeal for ENTYVIO\nThe following Letter of Appeal is a template which is intended to be modified by incorporating details related to your patient’s medical history, diagnosis, and treatment plan. Using this sample letter does not guarantee that insurance providers will provide reimbursement or coverage for ENTYVIO. Insurance providers may have specific forms or procedures for the authorization process that should be used instead of this template.\nDownload the Word doc template provided on page 2.\nGather all the details regarding your patient’s medical diagnosis and history and attach any supporting documents.\nRevise the Letter of Appeal based on the medical history for your patient. Fields in which patient-specific information can be incorporated are bracketed in MAGENTA.\nSubmit the revised Letter of Appeal with the prior authorization form to provide a more complete picture of your patient’s medical need for the insurance provider.\nScroll down to page 2 for sample Letter of Appeal.\nSample Letter of Appeal for ENTYVIO (prior authorization/general appeal)\n[Physician’s letterhead]\n[Date]\t\t\t\t\t\t[Patient’s name]\n[Health plan’s name]\t\t\t[Date of birth]\nATTN: [Department]\t\t\t\t[Case ID number]\n[Medical director’s name]\t\t\t[Date(s) of service]\n[Health plan’s address]\n[City, State ZIP]\nRe: Appeal of Denial for ENTYVIO® (vedolizumab)\nDear [Medical director’s name],\nI am writing to request reconsideration of your denial of coverage for [ENTYVIO intravenous (IV) infusions/ENTYVIO Pen for subcutaneous (SC) injection], which I have prescribed for [patient’s name]. I have read and acknowledged your policy for responsible management of drugs for moderately to severely active [Crohn’s disease (CD)/ulcerative colitis (UC)] [insert appropriate ICD-10-CM code here]. Your reason(s) for the denial [is/are] [reason(s) for the denial].\nBased on my medical care provided for this patient, I believe [insert reason for belief that treatment with ENTYVIO IV/Pen is medically necessary. If the denial is for the ENTYVIO Pen and the patient has been stable on ENTYVIO IV, affirm clinical response or remission to ENTYVIO IV].\nPatient diagnosis and medical history in support of the appeal\n[Patient’s name] is [a/an] [age]-year-old [male/female] who has been diagnosed with [CD/UC] as of [date of diagnosis]. [He/she] has been in my care since [date].\n[Include relevant medical information to support your reason for treatment with ENTYVIO. Include history of treatment. If patient is transitioning to ENTYVIO Pen for SC injection, include history of treatment on ENTYVIO IV.]\n[Additional information needed may include:\nSupporting documentation as requested by the plan in their denial letter\nDiscussion of clinical attributes of ENTYVIO and relevance to your patient\nYour assessment of why ENTYVIO is appropriate for this patient based on medical evidence]\nSummary\nThis is my [level of request] prior authorization appeal. A copy of the [level of denial] denial letter is included along with my medical notes in response to the denial. In my professional opinion and considering [patient name]’s history and condition, I believe [insert reason for belief that treatment with ENTYVIO is appropriate]. If you have any further questions about this matter, please contact me at [physician’s phone number] or via email at [physician’s email]. Thank you for your time and consideration.\nSincerely,\n[Physician’s signature]\nEnclosures\n[List enclosures, which may include:\nExplanation of benefits/denial letter\nCopies of original claim form\nLetter of Medical Necessity\nClinical notes/diagnostic pathology report\nMedication records\nRelevant laboratory reports\nENTYVIO Prescribing Information\nOther supporting documentation]\nUS-VED-1975v3.0 08/24","cbCaify4rRG1jSpb","https://ap.wps.com/l/cbCaify4rRG1jSpb","docx",37665,"English","# Guidance on Completing a Letter of Appeal for ENTYVIO\n## Sample Letter of Appeal for ENTYVIO (prior authorization/general appeal)\n## Patient diagnosis and medical history in support of the appeal\n## Summary\n## Enclosures","[{\"question\":\"What information should be gathered before completing the Letter of Appeal for ENTYVIO?\",\"answer\":\"Collect the patient’s medical diagnosis and history, then attach supporting documents requested by the plan in the denial letter.\"},{\"question\":\"What key elements should the sample appeal letter include?\",\"answer\":\"Include physician letterhead details, denial reason(s), the medically necessary treatment basis for ENTYVIO, and a section summarizing diagnosis and relevant clinical history.\"},{\"question\":\"How should the appeal be submitted to the health plan?\",\"answer\":\"Submit the revised Letter of Appeal together with the prior authorization form so the insurer has a complete picture of the patient’s medical need.\"}]","Guidance on Completing a Letter of Appeal for ENTYVIO - Sample Letter of Appeal | DOCX"]