A ‘denial of care’ is when a health plan does not pay for services or refuses to agree to treatment. All health plans are required to contact you in writing about their decision to deny care. They must give you the reason for the decision and you have the right to appeal that decision. Denials may also include reimbursement decisions contrary to your plan. Keep the following points in mind to increase the success of your appeal:

  • When you speak to the representative of your health plan tell them you are appealing their decision and want to know how to do this.
  • Maintain a written record of all your contacts when you are appealing. Always write down the full name of the person you speak to, their role, the content of your conversation and the time and date of the call.
  • Follow all time lines and procedures for pursuing your appeal.
  • Submit your appeal in writing.
  • Exhaust all levels of appeal. Do not become discouraged and stop. It may be the last level of appeal, outside the company, that reverses the original decision.

Appeal tips: Documentation to include with your Part B redetermination request

When submitting your Part B redetermination request, make sure to submit the appropriate supporting documentation for the patient’s claim(s) in question so that we can consider all of the facts supporting your case. If supportive documentation is not submitted, your redetermination will be conducted using information in our possession.
Contractors have also been instructed not to request documentation from a provider or supplier for a State-initiated appeal. If additional documentation is needed, contractors should request that the submitter of the appeal (i.e., the State or the party authorized to act on behalf of the Medicaid State Agency) obtain and submit necessary documentation within 120 days of the initial determination.

Please remember that providers/suppliers, Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. This documentation should be supplied with the appeal request or at the request of the contractor. Failure to submit requested documentation in a timely manner may result in processing delays.

Please make sure all copies of documentation include the patient’s name and are complete, legible, and contain both sides of each page, including page edges. Complete copies should include specific records to support the services on the claim(s) you are appealing and would include, as applicable, the following documents (not all-inclusive list):

  • Physician progress notes
  • Physician orders
  • Nurses’ notes
  • Medication records
  • Graphic reports
  • Operative reports
  • Pathology reports
  • Consultant notes
  • All laboratory reports
  • Diagnostic test results (regardless of where they are performed)
  • History and physical notes
  • Hospice records
  • Home health progress notes
  • Certificate of medical necessity
  • Skilled nursing facility records
  • Ambulance records
  • Emergency room records
  • above list may be used as a guideline (not all-inclusive list) when submitting documentation with your redetermination request.

Sample appeal Letter

[Physician Letterhead]

Attention: Appeals Department
Reference Number: [__]
[Payer contact name]
[Payer contact title]
[Street address]
[City, State, zip code]
Re: Request for Reconsideration of Denied Claim or Pre-Authorization
Patient name: [First and last name]
Patient date of birth: [XX/XX/XXXX]
Date of Service: [XX/XX/XXXX]

CPT‡ Code:
[93580 – Percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant]

Dear [Payer contact name]:

I am writing to request reconsideration of the denial of prior authorization for the above-referenced service. The service to be provided is a medically necessary implant of the Amplatzer™ PFO Occluder on an [inpatient / outpatient] basis to be provided to [patient’s name] on [procedure date].

In my last communication, I explained why the Amplatzer™ PFO Occluder is medically necessary to reduce the risk of secondary stroke in this otherwise healthy patient. I urge you to reconsider your denial of prior authorization in light of the patient’s specific clinical need, as well as the evidence for this technology, including its FDA approval.

To further substantiate my request please note that an Amplatzer™ PFO Occluder is medically necessary for this patient based on a comprehensive neurological assessment which determined this patient suffered from an ischemic stroke of undetermined etiology – the so called cryptogenic stroke. As described in my earlier request, documentation by the referring physician, in addition to my examination, supports the determination of this patient’s need for PFO closure.

[Insert paragraph explaining, in your own words, why the PFO closure is medically necessary for this patient. Consider documenting how the patient’s condition reflects the on-label use of the product; why less extensive interventions are inadequate in light of the patient’s condition; and your expectations of the patient’s outcomes without the PFO closure procedure. Please remember that the Amplatzer™ PFO Occluder is FDA approved to be used for the following indications: percutaneous transcatheter closure of a patent foramen ovale (PFO) to reduce the risk of recurrent ischemic stroke in patients, predominantly between the ages of 18 and 60 years, who have had a cryptogenic stroke due to a presumed paradoxical embolism, as determined by a neurologist and cardiologist following an evaluation to exclude known causes of ischemic stroke. Where accurate, please describe how the intended use is consistent with the FDA approved indication.]

I am attaching the patient’s medical record information and letter of medical necessity from my previous request.

[Include the following statement if additional information to be attached]

As explained above, I believe that in this case the Amplatzer™ PFO Occluder implant is medically necessary for this patient and as such this service should be granted coverage and paid for by your organization accordingly. Please let me know if I can provide any additional information, and thank you for your attention.

[Physician’s name and credentials]
[Name of practice]
[Street address]
[City, State, zip code]
[Phone number]