Urgent® PC
Appeals

Whether it's a denial of coverage from a private payer Prior Authorization or a denial of payment after Claim Submission, you and your patient have a right to appeal. Coverage is sometimes denied because the payer does not fully understand Urgent PC and percutaneous tibial nerve stimulation. Consequently, providing additional information to them can be helpful.

Keys to a Successful Appeal
The appeal process ensures that critical patient care decisions are given the consideration they deserve. The information on this website is designed to support you through the process. Uroplasty, Inc. cannot guarantee your success in gaining coverage. There are several tools that, when used together, give you the best chance to overturn a denial.

First, address the stated reason for the denial.

If the denial is based on therapy being "investigational/experimental"
The provider should 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 supporting information, such as the FDA letter and clinical documents. A copy of this letter should be provided to the patient for his/her records. For faster results, call the payer. This Sample Appeals Letter is available for your use.

If the denial is based on the PTNS not being "medically necessary"
Step 1: Ask the patient to send a letter to the payer requesting that the coverage decision be reversed. The letter should be submitted within the deadline mentioned in the denial notice, usually 1 - 4 weeks.The letter should contain relevant information about the patient, his/her condition, and the therapy.  For faster results, call the payer. This Sample Patient Letter is available for patients' use.

Step 2: Send a second letter from your office/clinic asking the payer to reconsider the decision to deny coverage. This letter should contain supporting information such as the FDA letter and clinical documents.  A copy of this letter should be provided to the patient for his/her records. For faster results, call the payer. This Sample Appeals Letter is available for your use.

The following Flowcharts represent the appeals process in various situations. Click on the image to view a larger version.

MEDICARE

PRIVATE PAYERS

Prior-Authorization/ Pre-Determination Appeal Process	Claim Appeal Process

Appealing a coverage decision can be a lengthy process. Do not get discouraged. There are resources available. You may contact the Uroplasty Reimbursement Group at 866-258-2182 to guide you in the appeal process.