Section 9: Denials Even with a comprehensive approach to preauthorization, you may occasionally receive denials from health plans. The following guidelines are based on industry-standard appeals processes. Most health plans have a three-level documented appeals process. If the health plan issues a denial to a preauthorization or a claim, it is advised that you inquire about the plan’s appeal process so you can initiate it.
Recommended Steps: • Request a copy of the denial in writing • Determine the reason for the denial (coding, technology, or medical necessity) • Reconsideration – Request a peer-to-peer review – surgeon to health plan Medical Director – focusing on benefits of treatment and its medical necessity • First Level Appeal – Include letter of appeal, medical necessity justification, successful outcomes, description of procedure, operative report and any peer reviewed literature to support your position • Second Level Appeal – Request a specialty matched external review from a Board Certified Physician (Neurosurgeon or Orthopaedic Spine Surgeon) with experience in posterior fixation instrumentation during spinal fusion following a decompression procedure. • Third Level Appeal – Request independent external review
The following are examples of an appeal letter and a hypothetical operative report which may be utilized in the appeal process: • Sample letter of appeal for a predetermination denial • Sample operative report
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