How Do I Appeal an SI Joint Fusion Denial from My Insurance Company?

Insurance Coverage Denials for SI Joint Surgery

1. Understand Why It Was Denied

In some cases, authorization of SI joint treatment services may be denied because the payer does not have enough information to make a favorable coverage decision. Their “letter of denial” may give one or more of the following reasons the payer will not cover your iFuse procedure:

• The treatment is “investigational” or “experimental.”
• The treatment is “not medically necessary.”
• The treatment is “not the standard of care.”

Understanding the payer’s reasoning for denial is very important because it will help you and your surgeon develop an appropriate approach for a successful appeal and gather the necessary supporting documentation.

2. Fully Understand Your Policy Requirements

The appeal process is designed to ensure that all critical decisions affecting your care, including whether you receive the iFuse procedure, is given the consideration it deserves. Note that all insurance policies differ and that the steps outlined here are not reflective of all policies. Be sure to take the time and understand your specific policy requirements, and adjust your appeal to-do list accordingly.

3. Take Steps to Appeal the SI Joint Treatment Denial

Take these steps for the best chance of overturning your SI joint fusion or iFuse denial:

1. Medical records: Obtain copies of your medical records, including a history of treatments you tried prior to the recommendation for the iFuse procedure. These records can be obtained from your primary care physician, pain management specialist, physical therapist, chiropractor, and other healthcare providers involved in your care for this condition.
2. Patient appeal in writing: Send a letter to the payer requesting that the coverage decision be reversed. The letter must be written within the deadline mentioned in the denial notice, typically within one to four weeks, and it should contain relevant information about you and your condition (see SI-BONE Insurance Support). Include evidence that supports the medical community’s consensus that your provider’s recommendation for treatment is a standard practice (reference the ISASS guidelines) and copies of peer-reviewed clinical evidence on minimally invasive SI joint fusion, available via PubMed.
3. Surgeon involvement: Ask your surgeon to write a formal letter requesting coverage and submit supporting documentation on the medical justification and necessity of the iFuse procedure in your case. If your surgeon receives a denial, ask that your surgeon call the payer and request to speak with the medical director of the insurance plan. Physicians are allowed the opportunity to participate in peer-to-peer reviews in most insurance plans. Your surgeon has access to SI-BONE reimbursement resources that will support this peer-to-peer review.
4. HR involvement: Consider keeping your Human Resources team and/or Plan Administrator at your company informed of your challenges with obtaining an authorization for surgery, including the impact on your quality of life and your family’s life. Your Human Resources team may be able to offer guidance on requesting an approval for the procedure based on medical necessity, and may also write a letter to your insurance company on your behalf.
5. Persistence pays off: Be persistent and follow up with your surgeon’s reimbursement administrator and payer staff on all correspondence and progress. Often, the surgeon’s staff is willing to help, but it is important for you to be in charge of the process and take responsibility to keep it moving along. Remember, this can be a time-consuming process and the doctors, nurses, and others are working with many other patients at the same time, and your paperwork can get overlooked.
6. Exhaust all appeal options: Throughout this process, remember that even if your insurance plan denies the initial appeal, insurance companies typically allow additional levels of appeal where your case is reviewed and reconsidered for approval. If you do not win your appeal at the first level, continue appealing to the next level until you have exhausted all your appeal options.
7. Keep good records: Maintain proper records and complete documentation. Note the dates, contact persons, and nature of your discussions. For example, record the types of correspondence with your insurance company (include the name and title of the person with whom you spoke, the date and time, and details of each conversation). Also, request copies from your surgeon's office of any correspondence related to your appeal that was presented to the payer. These steps will help you stay on track with the overall coordination of your appeal.

We believe you should be an informed, empowered, and an active participant in your health. When patients are forced to appeal their insurance denials while struggling with SI joint pain, the experience can be overwhelming and unsuccessful. That's why we offer you our services and look forward to assisting you in this process.

Talk to SI-BONE’s Reimbursement Support Team by calling 800-710-8511 or by email at PICS@si-bone.com.