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How Do I Write a Quality of Life Letter to My Insurance Company?

If your health insurance company denies coverage for the iFuse Implant procedure, options are still available. Patients and providers have options to appeal with hopes to overturn the denial. The best way to support an appeal is to provide your insurance company with a Quality of Life Letter.


SI Joint Surgery Insurance Coverage

A Quality of Life Letter is written by the patient and describes how sacroiliac (SI) joint pain negatively affects life.

The goal of this letter is to describe the impact of the condition SI joint dysfunction on your health and support the “medical necessity” for the procedure. Among other required application steps, this letter may help your insurance company approve your claim.

Here is a list of things to include in your letter that your insurance company may be looking for.

SI Joint Quality of Life Letter Checklist

  1. Start from the very beginning. How and when did the condition start? Did you immediately seek medical care?
  2. Provide a description of your overall health, and the impact of the condition on your quality of life (e.g., does or has it had a negative impact on your family, job, sleeping, and other daily activities).
  3. Describe your pain. Does your sacroiliac (SI) joint condition cause pain? Explain the pain in detail: does it always hurt, or does it hurt only while performing certain activities?
  4. List any medications you take and/or have taken to mitigate the pain. List tried and failed medications.
  5. List all the ways you manage the pain on your own. Describe what works, how well it works, and what you've tried that doesn't work.
  6. Describe any conservative therapies you've tried to manage your SI joint condition. Describe treatments tried and failed prior to becoming a candidate for SI joint fusion surgery (e.g., multiple SI joint injections, home exercise, radiofrequency ablation, chiropractor/physical/aqua/other therapy).
  7. List any surgeries you've had for this condition or that might have led to this condition.
  8. Describe your future. What are your plans? Does the SI joint condition hold you back and limit your possibilities? What do you anticipate will happen if this procedure is not approved? How will that lead to additional concerns?
  9. Be honest and clear. You want to explain the impact of your SI Joint condition and show how your diagnosis and treatment history has brought you to this place. Consider explaining that there is no other reasonable option to what you are asking, and the alternative is not preferable.

Example SI Joint Quality of Life Letter

(This template letter is provided as a courtesy. Do not include statements or elements that do not apply to you.)


Patient First Name, Last Name
Address
City, State, Zip Code
Phone Number
Email
Date

Name of Insurance Plan
Address
City, State, and Zip Code

Re: Authorization Request for Minimally Invasive Surgical Sacroiliac (SI) Joint Fusion

Patient Name
Member ID
Member Group Number
Procedure: CPT 27279
Diagnosis code from physician (If Known)

Dear Sir or Madam:

I wish to request an approval for minimally invasive SI joint fusion. I have suffered for the past [insert time] with an extremely painful and physically disabling SI joint condition. I am requesting an individual evaluation of the details of my case to reconfirm the medical necessity of SI joint fusion. All alternate treatment options have been discussed with my surgeon, who agrees that surgery is appropriate. It is my surgeon’s clinical opinion that I am an excellent candidate for SI joint fusion.

Impact of SI Joint Condition on My Life

[Using the Quality of Life Checklist we provided, paint a descriptive, detailed picture of your condition in your own words here. Add additional items if applicable and don't include items that do not apply to you.]

I am requesting your approval for minimally invasive SI joint fusion as prescribed by my surgeon, [Surgeon Name]. I look forward to a positive response.

Sincerely,

[Your name]

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This letter information is provided for convenience only. It is neither legal advice nor official payor guidance. SI- BONE does not warrant or guarantee that the use of the information will result in coverage or payment. Providers are solely responsible for determining medical necessity and for being in compliance with Medicare and other payor rules and requirements, as well as for the information they submit with claims and appeals. Before any claims or appeals are submitted, providers should review official payor instructions and requirements, confirm the accuracy of their coding or billing practices with these payors, and use independent judgment when selecting codes that most appropriately describe the services or supplies provided.

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