If your health insurance company denies coverage for the iFuse Implant Procedure, options are still available. Patients and providers have options to appeal with hopes to overturn the denial. The best way to support an appeal is to provide your insurance company with a Quality of Life Letter. A Quality of Life Letter is written by the patient and describes how sacroiliac (SI) joint pain negatively affects their life. The goal of this letter is to describe the impact of the condition SI joint dysfunction on your health and support the “medical necessity” for the procedure. Here is a list of things to include in your letter.
- How and when did the condition start? Did you immediately seek medical care?
- Does your sacroiliac (SI) joint condition cause pain? Explain the pain in detail; does it always hurt, or does it hurt only while performing certain activities? How do you manage the pain? If applicable, please list tried and failed medications and other therapies.
- Provide a description of your overall health, and the impact of the condition on your quality of life (e.g., does or has it had a negative impact on your family, job, sleeping, and other daily activities).
- What have you personally done to manage your SI joint condition. Describe treatments tried and failed prior to becoming a candidate for SI joint fusion surgery (e.g., multiple SI joint Injections, home exercise, radiofrequency ablation, chiropractor/physical/aqua/other therapy; or any prior surgeries).
- Describe your future. What are your plans? Does the SI joint condition hold you back and limit your possibilities? What do you anticipate will happen if this procedure is not approved? How will that lead to additional concerns?
- Be honest and clear. You want to explain the impact of your SI Joint condition and show how your diagnosis and treatment history has brought you to this place. Explain that there is no other reasonable option to what you are asking, and the alternative is not preferable.
Here is an example QOL letter:
Template Patient Quality of Life Appeal Letter
NOTICE TO PATIENT: This template letter is provided as a courtesy by SI-BONE, Inc.
Please do not include statements that do not apply to you.
(Remove before printing.)
Patient First Name, Last Name
City, State, Zip Code
Name of Insurance Plan
City, State, and Zip Code
Re: Authorization Request for Minimally Invasive Surgical Sacroiliac (SI) Joint Fusion
Member Group Number
Procedure: CPT 27279
Diagnosis code from physician (If Known)
Dear Sir or Madam:
I wish to request an approval for minimally invasive SI joint fusion. I have suffered for the past [insert time] with an extremely painful and physically disabling SI joint condition. I am requesting an individual evaluation of the details of my case to reconfirm the medical necessity of SI joint fusion. All alternate treatment options have been discussed with my surgeon who agrees that surgery is appropriate. It is my surgeon’s clinical opinion that I am an excellent candidate for SI joint fusion.
Impact of SI Joint Condition on My Life
(Paint a descriptive, detailed picture of your condition in your own words. Add additional items if applicable and remove items that do not apply to you.)
- [Share how/when the condition started.]
- [Describe the SI joint pain in your own words (hurts when I …).]
- [State when you were diagnosed with other conditions before the SI joint was identified as the true pain generator.].
- [Give a brief description of your medical condition, overall health, and the impact of the condition on your quality of life (e.g., laundry, cooking, grocery shopping, gardening, playing with grandchildren, and taking care of family members and pets).]
- [Describe treatments tried and failed prior to becoming a candidate for SI joint fusion surgery (e.g., multiple SI joint Injections, radiofrequency ablation, physical/aqua/other therapy, pain medications, other surgeries).]
- Describe what you anticipate will happen if this procedure is not approved and, if applicable, how that will lead to additional concerns, such as having no other treatment options except pain medication that is not controlling pain and possible risk of dependency.]
I am requesting your approval for minimally invasive SI joint fusion as prescribed by my surgeon, [Surgeon Name]. I look forward to a positive response.