Tips for a successful appeal
Whether you are denied iFuse Implant services by a commercial payer, Medicare plan or other provider, SI-BONE, Inc. is committed to providing you with the latest resources available to assist you in appealing your case.
While navigating the reimbursement process can be confusing, working with the appropriate people and gathering the right information can make it easier. Here are some tips you may want to consider as you begin seeking coverage for the iFuse Implant procedure:
- Know your healthcare insurance benefit plan administrator – Contact your insurance provider and ask if your specific plan includes coverage for the iFuse Implant procedure: CPT Code 27279 – Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixed devise.
- Determine if your plan is “administrative only/self-funded” or is a standard benefit plan such as an HMO/PPO. – Administrative only/self-funded plans means that the employer ultimately pays for the requested medical services and not the insurance company administering the policy. This important factor will determine who ultimately decides on your appeal. Some employers require that you exhaust your appeal process with the administrative only plan first before they will consider overturning your denial. Be sure to understand exactly what kind of plan your employer has established by obtaining a copy of your employee benefit plan. In many cases, the employer will provide you with additional guidance when faced with an insurance denial.
- Contact the medical facility or surgeon’s office reimbursement administrator – This person can advise you on how long it should take to secure the prior authorization for the iFuse Implant procedure and serve as the point of contact for apprising you of the status of your pre-authorization and/or appeal. If your request is denied, this person, with your surgeon, can intervene on your behalf with the payer to explain your specific needs for the iFuse procedure.
- Contact SI-BONE, Inc. patient support resources – If you are experiencing an insurance denial, we can work with you and your surgeon’s office when possible to help you overturn your insurance company or Medicare administrator’s decision.
 CPT 2015 Professional Edition. American Medical Association . Page 142.
In some cases, authorization of services may be denied because the payer does not have enough information to make a favorable coverage decision. Their “letter of denial” may give one or more of the following reasons why the payer will not cover your iFuse procedure:
- The treatment is “investigational” or “experimental.”
- The treatment is “not medically necessary.”
- The treatment is “not the standard of care.”
Understanding the payer’s reasoning for denial is very important because it will help you and your surgeon develop an appropriate approach for a successful appeal and gather the necessary supporting documentation.
The appeal process is designed to ensure that all critical decisions affecting your care – including whether you receive the iFuse procedure – is given the consideration it deserves. Note that all insurance policies differ and that the steps outlined below are not reflective of all policies. Be sure to take the time and understand your specific policy requirements. There are four steps that can be taken to give you the best chance of overturning your denial:
- Patient appeal in writing – Send a letter to the payer requesting that the coverage decision be reversed. The letter must be written within the deadline mentioned in the denial notice, typically within one to four weeks, and it should contain relevant information about you and your condition (see SI-BONE Patient Appeal Guide).
- Surgeon involvement – Ask your surgeon to write a formal letter requesting coverage and submit supporting documentation on the medical justification and necessity of the iFuse procedure in your case. If your surgeon receives a denial, ask that your surgeon call the payer requesting to speak with the medical director of the insurance plan. Physicians are allowed the opportunity to participate in peer to peer reviews in most insurance plans. Your surgeon has access to materials through SI-BONE that will support this peer to peer review.
- Persistence pays – You should be persistent and follow-up with your surgeon’s reimbursement administrator and payer staff on all correspondence and progress. Often, the surgeon’s staff is willing to help, but it is important for you to be in charge of the process and take responsibility to keep it moving along. Remember, this can be a time-consuming process and the doctors, nurses and others are working with many other patients at the same time, and the paperwork can easily get overlooked.
- Keep good records – You should maintain proper records and complete documentation. It’s important to note the dates, contact persons and nature of your discussions. Be sure to request copies from your surgeons office of any correspondence related to your appeal that was presented to the payer. These steps will help you stay on track with the overall coordination of your appeal.
SI BONE believes patients should be an informed, empowered and an active participant in their healthcare decisions. When patients are forced to appeal their insurance denials while struggling with SI joint pain, the experience can be overwhelming and unsuccessful. We are proud to offer you our services and look forward to assisting you in this process.