Macroplastique® Denials and Appeals
Most payers cover urethral bulking injections. If your patient's payer denies coverage or rejects a submitted claim, you and your patient have a right to appeal. The appeal process ensures that critical patient care decisions are given the consideration they deserve.
Coverage may have been denied because the payer does not fully understand bulking procedures. Providing additional information to them can be helpful toward obtaining coverage. Cogentix Medical cannot guarantee your success in gaining coverage. However, the following are often key to a successful appeal.
Resubmit with Correct Diagnosis and CPT® Codes
When considering a denied claim or denied prior authorization, first confirm that appropriate diagnosis and CPT codes were presented. Incorrect diagnosis and CPT codes can be a reason for denial. If incorrect diagnosis codes were used, resubmit with appropriate codes.
If appropriate diagnosis and CPT codes were used, address the stated reason for denial in an appeal letter. "Investigational/Experimental" and "Not Medically Necessary" are two of the more common reasons for denying a claim or prior authorization/determination of benefits. The provider can submit an appeal letter asking the payer to reconsider the decision to deny coverage. The letter should be submitted within the deadline mentioned in the denial notice, usually 1-4 weeks. This letter should contain relevant patient medical records, duration of symptoms, previously attempted treatments, a brief explanation of the therapy and support documents, such as the FDA approval letter and clinical data. A sample appeal letter is available for your use.
We encourage patients to get involved in the appeal process by sending a letter to their payer requesting that the coverage decision be reversed. The letter should also be submitted within the deadline mentioned in the denial notice. The letter should contain relevant information about the patient, her condition, duration of symptoms, previously attempted treatments, etc.
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.