Samples
These made-up samples show what a packet looks like
Every sample is made up. None is about a real patient, and every page is marked SAMPLE.
i.The samples
Each sample opens as a PDF
Words in square brackets, such as the patient's name, stay blank in the samples. In a real packet, your staff fill them in your own system before your physician signs.
- WISeR resubmission, neck fusion
Original Medicare did not affirm a WISeR prior request for a front-approach neck fusion (CPT 22554).
- Texas plan appeal, lumbar spine MRI
A Texas fully insured HMO denied a lumbar spine MRI without dye (CPT 72148).
- Specialty review request, lumbar decompression
After a Texas plan upheld its denial of a lumbar decompression (CPT 63047), the office asks for a reviewer in the same specialty.
- Medicare Advantage request, neck fusion
A request made before care, asking a Medicare Advantage plan to reconsider a back-approach neck fusion.
- Medicare Advantage request, low-back epidural
A request made before care, asking a Medicare Advantage plan to reconsider a low-back epidural injection.
- Medicare Advantage request, facet nerve ablation
A request made before care, asking a Medicare Advantage plan to reconsider facet nerve ablation.
ii.Inside
Every packet has the same parts
- A letter in your practice's name that answers the plan's stated reason.
- A criteria table that lists each coverage rule, marked Shown or Not shown from your chart.
- An exhibit list of the chart pages to attach.
- A deadline sheet with the rule behind each date.
- A one-page brief for a peer-to-peer call, with requests made before care.
- A sign-off page. Nothing is sent until your physician signs.