Mary's Insurance Appeal for iFuse Success Story
- Back Story
- SI Joint Trauma
Mary's journey with SI joint pain led her to an SI joint dysfunction diagnosis and her doctor recommended treatment with minimally invasive surgery using the iFuse procedure, but her insurance claim was denied. Here's what she did about it. Mary's journey is based on an aggregate of several true patient stories with similar history and presentation.
Insurance Letter of Denial
In December 2013, Mary received a letter from her insurance company stating that the iFuse procedure that her doctor recommended had been denied.
The letter stated that the iFuse procedure would not be a covered benefit, because the device was considered investigational and experimental and that it was not the standard of care. What the letter did not state was how or why her insurance company came to this decision.
Mary was devastated when she learned of her insurance denial, but she was also angry and wanted answers. She wrote to the insurance company and asked them to reconsider. Writing a letter was helpful for Mary, but did not sway their decision.
Insurance Appeal Process
Mary continued to stick with the appeal process outlined by her policy and met every deadline. She requested the assistance of her surgeon’s office and even asked her employer to write a letter advocating for her doctor's iFuse recomendation.
After contacting SI-BONE’s Patient Insurance Coverage Support (PICS) team, Mary received additional resources and support such as the Clinical Evidence Summary and passed this important information along to her insurance company.
Mary continued to fight her appeal over a four month period of time, and to her relief, she and her surgeon’s office were notified by her insurance company that they reconsidered their decision and were authorizing the iFuse procedure.
The Keys to Mary’s Success
Following in Mary's footsteps may help if you find yourself in the same situation of insurance denial. Here's what she did to help her case for iFuse.
- Mary asked her surgeon, pain doctor, and physical therapist to write letters supporting her iFuse procedure.
- Mary asked her employer to write a letter explaining that she was a valuable employee to their small business and they were eager to have her return to her normal duties.
- Mary wrote a letter that explained how her quality of life was deteriorating, why her conservative therapy was no longer working, and described the amount of pain she was experiencing.
- Mary contacted the SI-BONE Patient Insurance Coverage Support team who provided her with guidance and insight to the appeal process. She received important clinical literature supporting the iFuse procedure and submitted this to her insurance company with her patient letter.
- Mary was persistent and met all the appeal process deadlines.
Mary’s strategy may not work for all patients, but it is important for every patient to understand their policy, the appeal process, and what you can do to influence a positive coverage decision.
The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months. The iFuse Implant System is also intended for sacroiliac fusion to augment stabilization and immobilization of the sacroiliac joint in skeletally mature patients undergoing sacropelvic fixation as part of a lumbar or thoracolumbar fusion. As well, the iFuse Implant system is intended for sacroiliac fusion in acute, non-acute, and non-traumatic fractures involving the sacroiliac joint.
There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, talk to your doctor and visit: www.si-bone.com/risks. Rx Only.