Patient appeal letter: Transarterial Radioembolization (TARE) for the treatment of Hepatocellular Carcinoma (HCC)

About these letters 

These patient appeal letters were developed by the Society of Interventional Radiology (SIR) Carrier Advocacy Work Group to help address insurance coverage barriers that negatively impact access to interventional radiology care. The work group creates evidence-based appeal letters to support patients facing denied prior authorizations, coverage determinations, or claims denials. Each letter is grounded in current clinical evidence and helps to establish medical necessity for the interventional radiology procedure. 

How patients use these letters 

These templates are intended for patients whose prior authorization, or medical claim has been denied. Take the following steps to complete the appeal letter.

• Fill in all requested information in both the top section of the form and within the body of the letter.
• Replace all “greyed boxes” with your information, including your name, date of birth, insurance details, and your physician’s name.
• Your name must be entered twice, once at the top of the document and once at the end.
• Before submitting, review the letter to ensure all fields are completed and no placeholders remain.
• Once completed, the letter can be submitted to your insurance company’s appeals department.
• Patients may also wish to review the letter with their physician or care team before submitting it.
• Your physician may be able to provide additional documentation, such as a letter of medical necessity or medical records, to help support your appeal.

⚠️ Important – Complete All Sections Before Submitting

• Fill out the top section with your personal and insurance information.
•  Replace all “greyed boxes” throughout the letter with your information.
• Your name must be entered twice.

 ✔ Make sure no “greyed box” text remains
✔ Confirm all information is accurate and submit the letter to your insurance company via their appeal process as instructed by your insurance company.