If your request for surgery has been denied as “experimental or investigational,” below are some steps that you can take to support an appeal:
- Request a letter of medical necessity from your surgeon detailing why minimally invasive SI joint fusion is medically necessary. A template letter is available from SI-BONE’s Reimbursement Team.
- Obtain copies of your medical records, including a history of treatments you tried prior to the recommendation for the iFuse procedure. These records can be obtained from your primary care physician, pain management specialist, physical therapist, chiropractor, and other healthcare providers involved in your care for this condition.
- Include evidence supporting the medical community’s consensus that your provider’s recommendation for treatment is a standard practice (i.e., reference the ISASS guidelines) https://www.isass.org/pdf/Advocacy-Proposed-Recommendations-MISJF-2014-03-31.pdf.
- Include copies of peer reviewed clinical evidence on minimally invasive SI joint fusion, available via PubMed: http://www.ncbi.nlm.nih.gov/pubmed/?term=minimally+invasive+sacroiliac+joint+fusion+iFuse
- If you do not win your appeal at the first level, continue appealing to the next level until you have exhausted all your appeal options. Throughout this process, it is important to remember that even if your insurance plan denies the initial appeal, insurance companies typically allow additional levels of appeal where your case is reviewed and reconsidered for approval.
Keep detailed records:
- Create a log to record the types of correspondence with your insurance company (include the name and title of the person with whom you spoke, the date and time, and details of each conversation).
- Consider keeping your Human Resources team and/or Plan Administrator at your company informed of your challenges with obtaining an authorization for surgery, including the impact on your quality of life and your family’s life. Your Human Resources team may be able to offer guidance on requesting an approval for the procedure based on medical necessity.
SI-BONE’s Reimbursement Support Team can be reached at 800-710-8511 or by email at PICS@si-bone.com.