Urgent® PC Prior Authorization or Predetermination of Benefits

Medicare

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Medicare does not currently require prior authorization.

Private Payers

Cogentix Medical recommends the provider initiate the following:
  1. Contact the individual payer to obtain prior authorization/pre-determination of benefits before initiation of treatment.
  2. Review available coverage policies and/or contact the payer to determine if the patient meets their coverage criteria for percutaneous Posterior Tibial Nerve Stimulation (PTNS), CPT® code 64566.
When requesting a prior authorization/pre-determination:
  1. Confirm the diagnosis and CPT® codes are those recommended by the payer. Incorrect coding can be a reason for denial.
  2. Request prior authorization for all 12 initial weekly treatments.
  3. Determine if the payer requires a written prior authorization/pre-determination request. Some payers have their own form which must be used. For your convenience, Cogentix Medical has created a generic Prior Authorization Request Form and a Sample Letter of Medical Necessity (LOMN) for requesting prior authorization/pre-determination.

Prior Authorization Appeals

The prior authorization/pre-determination request may be denied because the payer does not have enough information to make a favorable coverage decision. You may have the right to appeal a denied prior authorization/pre-determination and should consult the individual payer for the required appeal process.

If a prior authorization/pre-determination is denied, providing additional documentation and supporting the reason for the authorization request may help. Sample appeal letters and other documentation are available to support you in the appeals process. To learn more, visit the Denials and Appeals page.

Cogentix Medical has compiled this coding information for your convenience. This information is gathered from third party sources and is subject to change without notice. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. It is always the provider’s responsibility to determine medical necessity and submit appropriate codes, modifiers, and charges for services rendered. Please contact your local carrier/payer for interpretation of coding and coverage. Cogentix Medical does not promote the use of its products outside their FDA cleared or approved labeling.