Free appeal letter 30Free appeal letter 30Free appeal letter 30
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Sample Letter to Appeal Denial SpaceOAR® System
Instructions: This template is designed to assist providers in appealing a denial of the
implantation of a hydrogel perirectal spacer. Although this information is designed to assist
with appealing coverage for the insertion of a perirectal hydrogel spacer only, providers may
utilize it in securing coverage for the patient’s entire episode of care when combined with
prostate radiation therapy treatment. Areas in red indicate variable patient-specific
information. Please insert the information pertinent to your patient and his individual
condition. Also, physicians are encouraged to include their professional opinions and
experience with this procedure. This template is not intended to replace any professional
judgment; it is merely intended to assist with organizing and structuring the appeal, and
make the case for medical necessity. Finally, it is recommended that one use his own
internal letterhead as deemed appropriate by one’s interna