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The staff at Stenum Spine will work with you to prepare your insurance documentation regardless of your carrier.
Insurance Process for US Patients
First, proceed with the diagnosis and evaluation process to obtain the specific procedure/device options available for your case.
Click here to begin this process.
Once you have completed the evaluation process you can work with Stenum to determine if any of the options provided are currently being covered, or will soon be covered, by US insurance carriers.
The Next Step
While Disc Replacement (limited devices, single level) is approved by the FDA, getting it covered by your insurance may be difficult. The following will help you understand the process and improve your chances of getting reimbursed for your surgery.
Prior Authorization Request
Stenum Spine can help with a prior authorization request to your carrier.
We can draft a letter of medical necessity describing the medical need and why we believe Disc Replacement is the best solution.
• If the carrier decides to cover the procedure, they will inform our office. This does not mean that we will accept this as payment.
• If the carrier decides not to cover the procedure, you have the right to appeal that decision.
Insurance carriers in the US are constantly updating coverage policies and are often paying claims on appeal. Although the FDA has determined that Disc Replacement is safe and effective, many insurers still consider Disc Replacement experimental/investigational. In addition, they may take a position that all new devices approved by the FDA maintain non-coverage positions until the long-term studies are published.
Your Right to Appeal
If your payer denies coverage for Disc Replacement, you have a right to appeal. Coverage is sometimes denied because the payer does not understand Disc Replacement technology. Consequently, providing information to them can be helpful. Be sure to check your policy handbook for instructions on the appeal process offered by your insurance plan.
Appeal
1. Send a one or two page letter written by you to the carrier requesting that the coverage decision be reversed. Your letter should be written within the deadline mentioned in the denial notice, usually 1-4 weeks. It should contain relevant information about you, your condition, and the therapy.
Our office can provide a sample appeal letter and supporting documents.
2. Ask Stenum to send a second letter asking the carrier to reconsider the decision to deny coverage. This second letter will contain additional supporting information about your condition, and the indications for Disc Replacement.
3. Be persistent. Follow up with the carrier. The Stenum staff are able to help out (write letters, make calls, etc.) but you need to be in charge of the process.
4. Write down each contact you make with your doctor, office staff and carrier.
5. Contact the Insurance Commissioner in your state to get help securing your reimbursement.
You can find your Insurance Commissioner at http://www.naic.org/state_web_map.htm
Please note: The staff at Stenum Spine will work with you to prepare your insurance documents regardless of your carrier. However, as with any medical procedure, it is the patients ultimate responsibility to pay the provider. In most cases we still require patients to pre-pay for surgeries due to the unreliable payment process which seems to plague many insurance systems. Stenum does not have the resources to provide insurance collection services, should your carrier deny coverage, or simply not pay. Lately we have seen improved success with patient reimbursement for Disc Replacement on appeal.
Click here to begin the evaluation process.
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