Urgent® PC Denial and Appeals

iStock_000016261283-edited.jpgWhether you receive a prior authorization or claim denial, you and your patient have a right to appeal. The appeal process ensures that critical patient treatment decisions are given appropriate consideration. When appealing, please refer to and follow the payer's appeal process.

Coverage for treatment may have been denied because the payer does not fully understand percutaneous Posterior Tibial Nerve Stimulation (PTNS) therapy using Urgent PC. Providing additional documentation to the payer may be helpful toward obtaining coverage.

The following pieces of information are often keys to a successful appeal:

  • Confirm correct diagnosis and/or CPT® codes were submitted: When presented with a denied prior authorization or claim, first verify that appropriate diagnosis and CPT codes were used. NOTE: It is always the responsibility of the provider to submit the most appropriate coding for the patient's condition or treatment.
  • Provider appeal letter: If appropriate diagnosis and CPT codes were used, consider addressing the denial of coverage in an appeal letter. The appeal letter should request the payer reconsider the denial and authorize coverage and payment based on medical necessity. The letter should be submitted within the deadline given in the denial notice or in accordance with the payer's appeal process.

The provider appeal letter should contain information relevant to the patient's medical condition, brief medical history, the duration of symptoms, previously attempted treatments, a brief explanation of PTNS and why it is the provider's treatment of choice. Additional support documents and clinical data may strengthen your argument. For your convenience, sample appeal letter is available.

  • Patient appeal letter: In accordance with the payer's appeal process, the patient may also have the right to appeal the denial for coverage. The patient appeal letter should contain relevant information about the patient's condition, duration of symptoms, previously attempted treatments, outcome of previous treatments and a brief explanation of PTNS. For your convenience, a sample patient appeal letter is available.

Key Resources

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.