Dynesys® Dynamic Stabilization System - Appeals

An appeal is a request for review of a denied claim or service. Claims may be denied for many reasons, including the result of health plan errors, inaccurate patient or claim information submission, inaccurate coding or health plan coverage policy. Prior-authorization is typically denied because the payer could not determine the medical necessity and appropriateness of the proposed treatment, level of care assessment and/or appropriate treatment setting or the services are deemed experimental or investigational. The reason for the denial can be found in the denial letter and/or the explanation of benefits (EOB). If a claim or service is denied, an appeal may be filed with the insurance carrier. (See Appealing Denials Process Flowchart on page 15).

Depending on the payer, the level of appeal may be considered a reconsideration, redetermination, grievance or an appeal. Each payer may have differing administrative requirements for each of these depending on their own definitions. Because payers have different appeal processes, we suggest contacting the payer directly to verify their appeal requirements.

Some payers have specific forms, phone numbers and addresses that must be used to submit an appeal. Please contact your payer to see if there is an identifiable appeal process that should be followed. Payer-specific guidelines for appeals may also be found online. If a payer has a standard appeal form, fill it out and submit it with all other supporting documentation that proves the need for coverage.

The following are some suggested questions to ask the insurance representative regarding their specific appeals process:

  • Does the appeal request have to be completed by the health care provider or the patient?
  • Is there a particular form that needs to be completed?
  • Can this form be faxed or mailed?
  • If faxed, what is the fax number? If mailed, what is the appropriate address?
  • Is a letter of medical necessity required?
  • What is the time limit for requesting an appeal?

When requesting a review of the denied claim or service, the request must meet the following requirements:

  • The request must be in writing.
  • Include reasons why the denial is incorrect.
  • Include any new and relevant information not previously submitted, such as the procedure dictation notes.
  • Must be requested within the period of time allotted by the payer's guidelines. Please be advised that the appeal guidelines and timeframes are provided in the letter of denial. If the denial letter is not readily available, contact the payer's appeal department for instructions.

If the payer does not have a required appeal form, submit an appeal letter (See Appendix C: Sample Prior-Authorization Appeal Letter and Appendix D: Sample Appeal Claims Denial Letter). The appeal letter should be tailored to the reason for the denial and may include a corrected claim, product information, patient medical information, clinical data, and/or economic data along with other supporting documentation.

The Centers for Medicare and Medicaid Services (CMS) defines medical necessity as those services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. The term medical necessity is usually used to determine whether or not a procedure or service is covered by CMS. The appropriate diagnosis, treatment and follow-up care plan, as determined and prescribed by the health care provider, should fit the patient's specific diagnosis. To establish medical necessity, the physician must clearly describe the condition(s) that justify the medical service provided.

The more complete and detailed an appeal is, the more successful it is likely to be. That is, the specificity of the medical necessity information and the documentation provided are key to the success of the appeal. It is critical to the appeal process that the health care provider attach any medical documentation that may support the medical necessity of the services being provided.

The supporting medical documentation listed below is an example of the type of information that may be submitted in order to support the claim for payment or a service for approval:

  • Physician's order
  • Medical history
  • Physician's notes / nurse's notes
  • Procedure dictation notes
  • Test results
  • X-ray results
  • Consultation reports
  • Plan of treatment
  • Referrals
  • Product information
  • Specific reasons the physician believes that the use of the Dynesys System is medically necessary
  • Relevant clinical data
  • List of conservative or alternative treatments that failed
  • Discharge notes

If the claim or service is denied by the insurer's internal department and the intent is to continue the process of either obtaining a prior-authorization or appealing a denied claim, state-specific and payer-specific guidelines must be followed to elevate the appeal to a higher level. The type of insurance determines whether federal or state laws apply to the appeal process. If the plan is self-funded through an employer group then the Employee Retirement and Income Security Act (ERISA) applies and the Department of Labor has jurisdiction. If it is commercial insurance, state law applies and the state Division of Insurance (DOI) has jurisdiction.

Additional Resources

Appealing Denials Process Flowchart

Download Complete Reimbursement Kit PDF

Reimbursement Kit Chapters

Overview
Payer Coverage
Insurance Verification Process
Prior Authorization Process
Coding Guidance
FAQs
Sample Letters
Disclaimer