Sample Preauthorization Letter Re: Patient’s Name: Date of Birth: Subscriber/Policy #: Group #:
To Whom It May Concern:
This letter serves to establish favorable coverage for the fusion procedure for the above referenced, patient who suffers from (L3-L4 degenerative disc disorder and associated spondylolisthesis). (Patient’s Name) has suffered from back and radicular leg pain since (enter start date of pain), despite efforts to control (his/her) symptoms using physical therapy, medication and lifestyle changes. (Patient ‘s Name)’s symptoms have significantly impacted the (his/her) lifestyle, job, family, and well being. (Patient’s Name)’s symptoms have progressed to the point that surgery is required. I am recommending a posterior spinal fusion in conjunction with surgical decompression and posterior fixation. My preference is to perform a standard posterior fusion with decompression with fusion utilizing spinous process fixation to help facilitate the fusion at the (L3-L4) level. For this patient I prefer a technique that ensures a small incision in the lower back. The decompression will be performed prior to the insertion of posterior spinal instrumentation. Bone will be placed over the posterior fusion bed and the Aspen device will be inserted and precisely fixated onto the posterior spinal segment, and permanently implanted. This instrumentation is intended to achieve supplemental fusion in patients who suffer from degenerative disc disease, spondylolisthesis, trauma and/ or tumor. The coding for the intended procedure is 22612 (posterior fusion, lumbar), 63030 (decompression), 22899 (unlisted procedure, spine) and 20930 (allograft for spine surgery). The procedure requires general anesthesia and postoperative monitoring. I prefer to perform this procedure at (Name of Hospital). Therefore I request that you authorize coverage for this procedure including posterior spinal fixation instrumentation billed under CPT 22899 – unlisted procedure, spine. Because (Patient’s Name) is in considerable discomfort and (her/his) condition is impacting (his/her) quality of life, we appreciate your immediate attention to this request. If you have any questions concerning this request please do not hesitate to contact me at (phone number). Sincerely, Physician Name
Hotline: 855.438.5269 | Email: reimbursement@lanx.com
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