Dynesys® Dynamic Stabilization System - Prior Authorization Process
Medicare
The Medicare program does not provide prior-authorization, prior approval or a predetermination of benefits for any services. General coverage guidelines for many services can be found using the Medicare Coverage Database. The database is maintained by the Centers for Medicare and Medicaid Services (CMS) and is located on the CMS web site at http://www.cms.hhs.gov/mcd/overview.asp. In the absence of a local or national coverage determination, the local carrier will determine whether coverage is available for a service on a case-by-case basis.
An HMO Medicare Advantage program most likely will require prior-authorization of specified services, such as spinal surgery. Please verify prior-authorization guidelines with the payer.
Private Payer
The requirements of private payers for prior-authorization vary. Certain payers may require the health care provider to submit specific patient information for medical review. It is important to become familiar with each payer's prior-authorization guidelines. (See Prior-Authorization Process Flowchart on page 9).
Prior-authorization means that the insurer has given approval for a patient to receive treatment, a test or surgical procedure before it has actually occurred. A prior-authorization approval does not guarantee payment.
To prior-authorize a procedure before services are rendered, provide the following information to the payer's prior-authorization department:
- Diagnosis code(s)
- Procedure (CPT®) code(s)
- Description of the procedure
- Product-specific description, if required
- Any additional information requested by the prior-authorization department related to the patient's condition and procedural clinical evidence
A written prior-authorization request may be required by the payer. (See Appendix A: Sample Letter of Prior-Authorization and Medical Necessity). This requirement may vary by payer. Some insurers may require the submission of their own prior-authorization request form or a letter from the treating physician. (See Appendix B: Sample Letter of Medical Necessity). The prior-authorization request should include the following detailed information about the patient's medical condition and the reason for the patient to undergo treatment:
- The patient's medical condition with exact diagnosis and symptoms associated with the disease
- The medical necessity for the treatment and what health problems may occur if the patient does not undergo the procedure
- What other treatments or services the patient has already had, if any, and why these alternative treatments did not alleviate the symptoms
- A description of the treatment
- Why the procedure is the most appropriate treatment for the patient's condition
Typically, most payers will respond with a decision within 30 days. The health plan is required to provide a clinical reason for their decision, and whether they are approving or denying the request. If the prior-authorization is approved, document the approval number in the patient's chart should any questions arise at a later date
Additional Resources
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Overview
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Verification Process
Coding Guidance
Appeals
FAQs
Sample Letters
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