Learn how one patient got involved in her appeal process and won!
In December 2013, Mary received a letter from her insurance company stating that the iFuse procedure her doctor recommended had been denied. The letter stated that the iFuse procedure would not be a covered benefit because the device was considered investigational and experimental and that it was not the standard of care. What the letter did not state was how or why her insurance company came to this decision.
Mary was devastated when she learned of her insurance denial, but she was also angry and wanted answers. She wrote to the insurance company and asked them to reconsider. Writing a letter was helpful for Mary, but did not sway their decision. Mary continued to stick with the appeal process outlined by her policy and met every deadline. She requested the assistance of her surgeon’s office and even asked her employer to write a letter advocating for her doctor's iFuse recomendation. After contacting SI-BONE’s Patient Insurance Coverage Support (PICS) team, Mary received additional resources and support such, as the Clinical Evidence Summary, and was able to pass this important information along to her insurance company.
Mary continued to fight her appeal over a four month period of time, and to her relief, she and her surgeon’s office were notified by her insurance company that they reconsidered their decision and were authorizing the iFuse procedure.
What were the keys to Mary’s success?
- Mary asked her surgeon, pain doctor and physical therapist to write letters supporting her iFuse procedure.
- Mary asked her employer to write a letter explaining that she was a valuable employee to their small business and they were eager to have her return to her normal duties.
- Mary wrote a letter that explained how her quality of life was deteriorating, why her conservative therapy was no longer working and described the amount of pain she was experiencing.
- Mary contacted the SI-BONE Patient Insurance Coverage Support team who provided her with guidance and insight to the appeal process. She received important clinical literature supporting the iFuse procedure and was able to submit this to her insurance company with her patient letter.
- Mary was persistent and met all the appeal process deadlines.
Mary’s strategy may not work for all patients, but it is important for every patient to understand their policy, the appeal process and what you can do to influence a positive coverage decision.
If you are interested in learning more, please contact the SI-BONE Patient Insurance Coverage Support team by clicking here: