Uterine Fibroid Insurance Coverage Guide
for MR guided Focused Ultrasound Surgery -
Non-invasive Treatments
Dear Patient:
MR guided Focused Ultrasound Surgery (MRgFUS) for non-invasive
treatment for uterine fibroids is a new technology which received FDA
approval in October 2004. Due to its recent introduction within the
medical community, many health plans have not formally completed their
review of this technology or you may find that your specific health
plan may not currently consider MRgFUS as a covered benefit for treatment
of fibroids.
In spite of this you can always approach your carrier
and request that they consider your request on a case-by-case basis.
This is known as "pre-authorization" for treatment. This
process for getting your health plan to approve your MRgFUS procedure
may require that you and your referring physician dedicate some time
to navigate the pre-authorization process as defined by your health
plan. You may find that your health plan initially denies your request.
Do not be discouraged. This is their first response, not necessarily
their last.
This guide provides details on how to find out if your
health plan covers MRgFUS and for obtaining pre-authorization approval
for treatment. It overviews the steps you can follow if you have individual
health insurance or group health insurance through your employer. Your
MRgFUS provider, who will actually perform the procedure, can assist
you in your efforts to obtain pre-authorization and payment for this
procedure.
The steps described here include:
Step 1. Are you a candidate for MRgFUS treatment for
uterine fibroids?
Step 2. Is MRgFUS a covered benefit under your health
plan?
Step 3. Requesting pre-authorization for MRgFUS treatment
Step 4. Obtaining the decision
Step 5. Appealing a denial
Frequently Asked Questions regarding the reimbursement
process.
As more patients, such as yourselves, request coverage
and undergo MRgFUS treatment, the reimbursement process will get easier
and more health plans will cover this.
Step 1: Determine if you are
a candidate for MRgFUS Treatment for Uterine Fibroids
Contact your referring physician or the MRgFUS treatment
center to begin the prescreening process to determine you are a candidate
for MRgFUS treatment. Prescreening diagnostic tests may require pre-authorization
for the pre-treatment MRI and other diagnostic tests.
Once you have completed the required evaluation process
and it is determined that you are a candidate for MRgFUS treatments,
ask your physician to help you obtain preauthorization for the MRgFUS
treatment.
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Step 2: Contact your Health
Plan and Ask if MRgFUS is a Covered Benefit
Contact your health plan by phone or in writing to ascertain
if MRgFUS is a covered benefit for the treatment of uterine fibroids
under your plan. Provide them with the following MRgFUS Current Procedural
Terminology (CPT) procedure codes: CPT 0071T and CPT 0072T. Plans determine
this by reference to the codes used to bill for the treatment in question.
If they tell you it is an approved procedure under your
covered benefits, ask them to provide you with the details and steps
if you need to obtain pre-authorization of MRgFUS treatment.
If MRgFUS is not a covered benefit, ask why it is not
currently considered a covered service. They may answer that it is not
considered a "medically necessary" procedure for the treatment
of uterine fibroids, or it is considered an investigational or experimental
procedure or it is not considered a covered benefit under your specific
plan. Ask them what information and documentation you need to submit
to get them to reconsider their decision to deny this service. Record
all contact information (including the person you are talking with and
any person they recommend you contact) and what is discussed on the
phone conversation.
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Step 3: Request Pre-authorization
by Health Plan for MRgFUS Treatment
The MRgFUS center should be able to help you in your efforts
to secure preauthorization from the health plan.
The pre-authorization request should include the following
detailed information about your medical condition and your need to undergo
MRgFUS treatment, all of which should be furnished by your physician:
- Your medical condition with your exact diagnosis
(uterine fibroids) and your symptoms associated with your fibroids.
- The medical necessity for you to undergo MRgFUS and
a description of this procedure.
- What health problems could occur if you do not get
MRgFUS treatment.
- What other treatments or services you have already
had for your fibroids, if any, and why they these other alternative
treatments did not alleviate your symptoms.
- Why MRgFUS is the most appropriate treatment for your
uterine fibroids
Your physician may ask the health plan to call him or
her with any questions about the letter or the MRgFUS procedure. You
can get letters from both your referring physician and/or the physician
from the MRgFUS center that will be performing your MRgFUS treatment.
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Step 4: Followup after Submitting
Request for Pre-Authorization
Contact the health plan claims office if you don't receive
a reply within two weeks and ask when a decision can be expected. (Many
states require insurance companies to respond within 30 days). Record
the date of inquiry and the person with whom you spoke. Be patient and
offer to provide any needed information. Your health plan must provide
a clinical reason for their decision, whether they approve or deny the
request.
Your health plan may deny MRgFUS, because
- this medical procedure is not considered "medically
necessary"
- they consider MRgFUS to be experimental or investigational
at this time; or
- they do not offer this procedure under your health
plan to any plan participants and MRgFUS is not a "covered health
benefit" under your plan.
Whatever the reason for the denial you have the
right to appeal this, and should request details on these steps.
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Step 5: Appeal Procedure
If you are denied, don't give up! Persevere. This is their
first response, not necessarily the last. Request a written response,
detailing the reasons for denial. You will then have something specific
to answer.
The type of insurance you have determines whether state
or federal law applies to the appeal process. If your plan is self-funded
then ERISA (federal law) 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.
A. Reconsideration of Denial (grievance letter)
If your health plan denies your request for treatment,
you should request an informal reconsideration (grievance appeal). You
can do this by calling, writing or faxing the health plan.
Contact your health plan to provide you with the appropriate
guidelines for your appeal. It is better to ask for your reconsideration
in the form of a letter, so your request does not get lost. If you make
your request by phone, record the date and who took your request. Health
plans must send you a letter stating that they received your request
for informal reconsideration within 5 days.
In your letter, you should tell the health plan the reasons
why you disagree with their denial. If the reason for denial is that
the service is not considered medically necessary, ask your physician
to write a letter of medical necessity. Include in this letter, medical
records, and documentation that supports your position for coverage
in your informal reconsideration letter. You should also include published
information about ExAblate and MRgFUS, including the FDA approval letter
(http://www.fda.gov/cdrh/pdf4/P040003a.pdf
), the Talk Paper issued by the FDA to inform the public about ExAblate
(http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01319.html)
and the bibliography of articles about MRgFUS ( found on website: www.uterine-fibroids.org)
If the service is denied because it is "investigational"
this objection can be refuted by citing experience with over 1,200 uterine
fibroid treatments worldwide.
B. Written Appeal
If your health plan denies MRgFUS after an informal reconsideration,
you should send a written letter to appeal their decision. You may ask
your physician to write the response.
Check with your health plan for specific instructions
and how long the appeal process takes. It is very important to submit
your appeal as soon as you hear from your health plan that they have
denied your informal reconsideration.
Your appeal letter should directly address the reason
for the denial of MRgFUS. In the letter, include any additional information
not included in your informal reconsideration letter. If you did not
submit a letter of medical necessity with your informal reconsideration,
request your referring physician write a letter of medical necessity.
(See: Letters of Medical Necessity under Step 3).
Send the appeal to the claims manager (or the specified
contact). Call to make sure it was received.
C. Second Appeal
If the first appeal is denied, ask again for the denial
in writing. Also inquire if another appeal is possible, to a higher
level person or committee. Should you be denied a second time, do not
give up. Answer, or ask your physician to answer, all objections and
resubmit. Be patient and persistent. Many claims have been authorized
after two or more appeals
D. Higher Level of Appeal - External Independent
Review
You must check with your health plan to see if you have
the right to request an external independent review of their decision
to deny coverage of MRgFUS. Your health plan or employer can explain
to you whether your type of insurance allows for an external review
and the steps to take after your appeal is denied. An external independent
review requires that someone, who is not employed by the health plan,
review your request for MRgFUS treatment and make a decision independent
of the health plan. You must request this independent review within
a certain amount of time after the health plan denies your appeal for
MRgFUS treatment. Your request for this review should be mailed directly
to your health plan. Your health plan will send your request for an
independent review, along with all of your information, to the your
State’s Department of Insurance. There is no charge to you for
the external independent review.
For questions of medical necessity, the independent physician
who reviews your case has 21 days to contact the Department of Insurance
of his or her decision. The Department of Insurance will send you the
decision 5 days following receipt of the decision. For
questions of coverage, the Department of Insurance will mail you a decision
within 15 days of receipt of the independent physician’s review.
The external independent review decision is legally binding on your
health plan and you. On questions of medical necessity, if you disagree
with the independent review, you may have the right to go to court to
further your appeal. On questions of coverage, you or the health plan
can ask for a fair hearing with the Office of Administrative Hearings.
You have 30 days to request a fair hearing. Information sent with the
independent review decision will explain the process for requesting
a fair hearing.
Additional Information
Is the appeal process different if denial was
based on decisions of medical necessity versus questions of coverage?
Yes, the appeals process will differ depending why your
case was denied. The review process used will depend on whether your
case is based on the question of whether MRgFUS is medically necessary
or whether it is a question of coverage.
A question of medical necessity means that the health
plan does not believe that MRgFUS is necessary to treat your uterine
fibroids. In this case, a physician familiar with treating uterine fibroids
will review all the information you have submitted during the appeals
process and determine if MRgFUS is the most appropriate treatment choice
for your specific case.
A question of coverage means the health plan believes
that MRgFUS is not a covered benefit under the terms of your health
insurance policy. An employee of your State Department of Insurance
reviews questions of coverage.
For all independent reviews, it is very important that
write all the reasons why the denial of MRgFUS is the wrong decision
for your medical condition. Letters of medical necessity, your medical
records, and MRgFUS support documents from your treating physician and
the MRgFUS treatment center are critical for the independent physician
to review.
Once the external independent review is in process, contact
your State Department of Insurance directly to make sure they have all
your information.
For ERISA Complaints: If you are employed by
an employer group who is self-insured and does not buy insurance from
an insurance company and is self-funded (meaning that they provide their
own insurance and bear their own risk), your employer must follow a
federal law, the Employee Retirement Income Security Act, known as ERISA.
If your employer has self-insured health insurance, you cannot ask for
an external independent review through the State Department of Insurance.
Under ERISA, if your appeal was denied, you may be entitled to file
a complaint with the U. S. Department of Justice. You can contact them
at 1-666-444-3272 or visit their website at www.dol.gov/ebsa
for information on how to file a complaint.
What if i need MRgFUS Immediately and my health
plan denies my request?
If your health plan denies MRgFUS and it is determined
you need these treatment immediately, you can request an Expedited Medical
Review. The purpose of an Expedited Medical Review is to require that
the health plan to make a quick decision based on the fact that your
health is at risk. Your referring physician must certify in writing
that delaying this service could cause a significant negative change
in your medical condition. The health plan cannot question your physician’s
certification and it must make a decision 1 business day after receiving
the certification and other supporting information. If the health plan
still denies MRgFUS, you can appeal and ask for an external independent
review. The time period allowed for the health plan to respond to this
type of request is very short. Contact your State Department of Insurance
and request information on Expedited Medical Review.
Suggestions for contacting
your health plan:
- Always contact them in writing. Phone calls can be made, but written
communication is more powerful.
- Be sure to followup all written ommunications with a phone call
to make sure they received your letters.
- Keep a copy of all your letters for your records. Record all phone
calls in a phone log.
- Keep a log of when, where, and to whom you sent your request.
- Send important documents by certified mail (return receipt), Federal
Express, or by fax with a confirmation sheet.
Most importantly, be persistent.
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Patient Reimbursement Frequently
Asked Questions
- Will my insurance company
or health plan pay for MRgFUS?
Payment and coverage of MRgFUS will vary from health
plan to health plan. MRgFUS is a recently introduced new technology
for treatment of uterine fibroids and received FDA approval in October,
2004. Because this treatment option is relatively new, few insurance
companies reimburse for this as part of their routine treatment options.
It will be necessary for you to contact your health plan to verify
whether it is a covered benefit under your plan policy. At this time,
payment for MRgFUS is based on individual payer discretion and coverage
is typically determined on a case-by-case basis.
- Do I need to get pre-authorization
before treatment?
Yes, you will have to contact your health plan for pre-authorization
of MRgFUS treatment prior to scheduling your treatment session. You
may also have to get preauthorization for the pre-screening diagnostic
tests that are required to verify you are an appropriate candidate
for MRgFUS. We suggest you work with your referring physician and/or
staff at the MRgFUS provider site you have been referred to for treatment.
Your physician, or physician(s) at the MRgFUS site, will assist you
in your efforts to get pre-approval for MRgFUS. Prior to contacting
your health plan, we recommend your referring physician document the
reason MRgFUS is the most appropriate treatment for your specific
case. Either your referring physician, or a physician at the MRgFUS
provider site, will need to provide you with documentation that supports
medical necessity for treatment of your uterine fibroids and their
choice of MRgFUS as the best option.
- What should I do if my health
plan denies my request for MRgFUS treatment in this pre-authorization
process?
For MRgFUS to be approved by your health plan through
the pre-authorization process there are 3 conditions that must be
met:
- they must agree that treatment is necessary for
your condition,
- they must agree MRgFUS is an appropriate treatment
for your condition,
- they must agree to reimburse for this treatment.
If you complete the pre-authorization process and your
plan does not consider MRgFUS a covered benefit (or medically necessary)
and denies your initial request for treatment, you are entitled to
initiate a general grievance review of their denial decision. You
must contact your health plan to outline the protocol for the grievance
process. You will need to follow the guidelines established by your
health plan. You may also be entitled to a second more formal independent
review process if your health plan denies treatment under the grievance
process. You must exhaust the
grievance process before attempting to initiate the independent review
process.
- What are the reasons why
a health plan will deny MRgFUS treatment?
A health plan will base their denial on a combination
of three different rulings. The plan may rule that MRgFUS is a "non-covered
service" for its eligible members; it is "not medically-necessary"
for the treatment of uterine fibroids or for a patient specific case;
or even though it is an approved by FDA for this condition, from an
insurance company perspective they consider this an "experimental
or investigational" treatment. Your right to an external independent
review will be dependent on the reason cited for the denial and your
health plan’s eligibility criteria for an independent review
of a denial made through the grievance process.
- Do I need to write a letter
of appeal and forward it to my health plan?
For both the grievance and the independent review process,
you are typically required to formally appeal their denial decision
in writing. Prior to writing your appeals letter, go to the Web page
for your health plan, or contact them directly for specific instructions
on what written documentation is required to support your request
for a review if their decision to deny approval. Work with your referring
physician and staff to provide the appropriate documents you will
need to start the appeals process. In addition to a letter of appeal,
health plans require additional support documents including a letter
from your referring physician recommending MRgFUS and the reasons
why MRgFUS should be a covered benefit for your specific case.
Additionally, other support documents that are needed include peer
reviewed literature that demonstrates clinical efficacy and cost-effectiveness,
medical literature and second opinions supporting medical necessity,
copies of all information provided to the health plan during the appeals
process, and all documentation received from the health plan during
the appeals process documenting the reason for the denial.
- What happens if I exhaust
all levels of appeal?
Once you feel you have exhausted all avenues of appeal,
you may want to consider other options for MRgFUS treatment. Under
some health plans, there are legal remedies available under state,
federal, Medicare, or ERISA regulations. For those who seek treatment
outside of continued appeals or legal remedy, patient self-pay options
may be a viable consideration. The majority of MRgFUS provider sites
offer Self-Pay programs for patients desiring treatment. Please contact
either your referring physician or your local MRgFUS provider to discuss
financing options and alternative payment programs.
- Do I have any other choices?
Yes. Because for some patients the need for treatment
is urgent, or the patient feels this is the treatment method of choice,
many decide to move forward with the treatment and pay for the procedure
out of pocket. You must first contact your health plan and get a formal
denial of pre-authorization of MRgFUS. Once you have this denial,
you do have the right to appeal their non-coverage decision and denial
of payment and request, either through your employer or health plan
to be reimbursed for the expense.
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