Appeal Letter - Medicare

Please note: When billing ALOXI using J2469, the billing unit is 25 mcg.
ALOXI should be billed at 10 units for a 0.25 mg dose.

To view a sample of the Appeal Letter, simply click the "Sample Appeal Letter" button below.

You will need Adobe Acrobat Reader to view the Sample Appeal Letter.

To download a template of the Sample Appeal Letter that you can customize and submit to MEDICARE, simply click the "Appeal Letter" button below.

You will need Adobe Acrobat Reader to view the CMS 1500 Form (for physicians' office).


For a FREE download of Adobe Acrobat, click on the image below:

*ALOXI is used in adults to help prevent the nausea and vomiting that can happen on the day of treatment with certain chemotherapies or occur days later following certain chemotherapies moderately likely to cause nausea and vomiting.

Tell your healthcare professional if you are taking other medications or if you have or develop severe heartbeat changes. The most common side effects of ALOXI are headache and constipation. ALOXI is available by prescription only. For more information, please see the Patient Product Information for ALOXI.

This site does not contain everything that is known about ALOXI. If you would like to know more, talk to your healthcare professional.