[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-279671-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-279671-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","letter-of-medical-necessity-for-lupkynis-voclosporin-for-lupus-nephritis","Letter of Medical Necessity for LUPKYNIS (voclosporin) for Lupus Nephritis","","Patient-specific Letter of Medical Necessity templates support appeals for denied prior authorization of LUPKYNIS (voclosporin) coverage. The letter helps the prescriber document why a specific therapy is selected and includes fillable fields for patient demographics, diagnosis, ICD-10-CM code, prior treatments, responses, and clinical rationale. 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The goal is to explain medical necessity for coverage.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must the prescriber include in the letter?",{"text":68,"@type":64},"The template includes fillable fields for patient name, diagnosis, ICD-10-CM code, relevant medical history and laboratory results, prior therapies, and the patient’s response (including side effects or lack of response). It also includes the policy and claim numbers.",{"name":70,"@type":61,"acceptedAnswer":71},"Does using the template guarantee approval of the request?",{"text":72,"@type":64},"No. The template notes that using it does not guarantee the health plan will approve the request, and it does not replace the provider’s independent medical judgment.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},279671,1789525264,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,103,108,113,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":115,"slug":116},18,30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":22},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","1  \n[SAMPLE TEMPLATE: Letter of Medical Necessity for the use of LUPKYNIS ™ (voclosporin) for lupus nephritis]  \nA patient-specific letter of medical necessity is generally required to appeal a denied prior authorization for medication coverage. The purpose of the letter is to explain the physician's reasons for selecting a particular therapy. This sample templated letter of medical necessity contains suggested content with fields that can be filled in and customized based on your patient's personal and medical history. Note that some health plans have specific requirements for documenting medical necessity. Please check with your patient's health plan to be certain you are providing all required documentation.  \nIMPORTANT NOTE: Use of the Letter of Medical Necessity template does not guarantee that the health plan will approve your request for LUPKYNIS and is not intended to be a substitute or an influence on the independent medical judgment of the healthcare provider.  \nLUPKYNIS and Aurinia Alliance are trademarks of Aurinia Pharmaceuticals Inc.  \n©202 1 Aurinia Pharma U.S. , Inc. All Rights Reserved. US-VCS-2000147 01/21  \n2  \nDate: RE: Patient Name: [ ]  \n[Name of Prescriber] Policy Number: [ ]  \n[Health Plan] Claim Number: [ ]  \n[Address] Diagnosis: [ ]  \n[City, State, ZIP] ICD-10-CM Code: [ ]  \n[Note: This appeal letter should be written on practice letterhead after fully reviewing the health plan’s denial letter and medical policy for LUPKYNIS.]  \nDear [ Health Plan ] :  \nI am writing on behalf of [ patient name ] to document the medical necessity of LUPKYNIS™ (voclosporin) . LUPKYNIS is indicated in combination with a background immunosuppressive therapy regimen for the treatment of adult patients with active lupus nephritis (LN) . The treatment of [ patient name ] with LUPKYNIS is supported by the following information.  \n1. Patient medical history and diagnosis  \n[This section to be completed by the physician based on the patient’s medical history and prognosis. Be sure to include all information required by the health plan’s medical policy.]  \n[Diagnosis and current condition, including date of last evaluation][Relevant medical history, including laboratory results]  \n[Previous therapies the patient has undergone for the symptoms associated with his or her disease]  \n[Patient response to these therapies (including intolerable side effects, inadequate response, contraindications, and/or other considerations)]  \n2. Rationale for treatment  \n[Explain why you believe it is medically necessary for the patient to receive  \nLUPKYNIS. Describe the potential consequences to the patient if they do not receive LUPKYNIS.]  \nBased on the clinical data available to date, it is my medical opinion that treatment with LUPKYNIS for [ patient name ] is medically appropriate and necessary.  \nIf you have any further questions or if any additional information is required, please contact my office at [XXX-XXX-XXXX] . Thank you for your attention to this matter, and I look forward to receiving your response.  \nSincerely,  \n[Physician Name]  \n[Physician ID Number]  \n[Enclosures:]  \n[LUPKYNIS Prescribing Information]  \n[Patient medical records]  \n[Other relevant materials and supporting documents]  \nUS-VCS-2000147 01/21","cbCailhAL4qUWCLW","https://ap.wps.com/l/cbCailhAL4qUWCLW","pdf",147919,"English","# Date and patient/claim details\n## Prescriber and health plan information\n# Diagnosis and documentation placeholders\n# Medical necessity statement and treatment rationale\n## Medical history and diagnosis section\n## Rationale for treatment\n# Closing, contact, and enclosures","[{\"question\":\"What is the purpose of a Letter of Medical Necessity for LUPKYNIS?\",\"answer\":\"It documents the physician’s reasons for selecting LUPKYNIS and supports an appeal when prior authorization is denied. The goal is to explain medical necessity for coverage.\"},{\"question\":\"What information must the prescriber include in the letter?\",\"answer\":\"The template includes fillable fields for patient name, diagnosis, ICD-10-CM code, relevant medical history and laboratory results, prior therapies, and the patient’s response (including side effects or lack of response). It also includes the policy and claim numbers.\"},{\"question\":\"Does using the template guarantee approval of the request?\",\"answer\":\"No. The template notes that using it does not guarantee the health plan will approve the request, and it does not replace the provider’s independent medical judgment.\"}]","Letter of Medical Necessity for LUPKYNIS (voclosporin) for Lupus Nephritis | PDF"]