Appeal Letter Template for Septoplasty
In response to the denials some members have received for CPT code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), the Physician Payment Policy workgroup (3P) has drafted an appeal template letter that members may use to appeal these denials. This appeal template letter is also available at www.entnet.org/Practice/Appeal-Template-letters.cfm.This letter is generic and acts only as a guide to help you construct your appeal letter. You should use your company letterhead/logo and fill in the blanks and header information. Please remove the sections in the template letter that do not apply to your denial. We recommend that you also submit any other relevant supporting documents such as medical notes, operative reports, clinical indicators, etc. If you receive a denial for a septoplasty from United Healthcare, report this denial and the denial reason to healthpolicy@entnet.org or 1-703-535-3727. We encourage members to write us with relevant topics of interest in health policy and practice management. Please email us at healthpolicy@entnet.org. [Date] [Insurer Name] [Insurer Address] Re: Patient: [Name] Policy Number: Group Number: Claim Number: Date of Service: Dear [Medical Director]: Please consider this letter a formal request for reconsideration of a denial received for a septoplasty on [Patient’s Name] on [Date of Service] by [Name of Physician]. The [claim] [pre-certification] for the [septoplasty] was billed with CPT© code 30520 – Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft. If the pre-certification or the claim was denied because the patient’s condition was not chronic for more than two months or the patient did not have recurrent acute sinusitis, then you may include the text below in your template letter: I disagree with [insurer name]’s denial of the septoplasty based on your logic that the [Patient Name]’s condition was not chronic for over two months or that [s/he] did not have recurrent sinusitis. According to current medical practice, it is more clinically appropriate to document nasal obstruction that persists despite reasonable medical therapy (e.g., four to eight weeks). As a result, I believe that [insurer name]’s denial of this procedure is not justifiable. If the pre-certification or the claim was denied because you did not include a photograph of the external nose, then you may include the text below in your template letter: I disagree with [insurer name]’s denial of this septoplasty as medically unnecessary for [Patient Name] because I did not include a photograph of the patient’s external nose. Photographs will often not show a clinically significant septal deviation; only caudal deviations will be evident and photos generally demonstrate external nasal deformities. As such, I believe that [insurer name]’s denial of this procedure is not justifiable. If the pre-certification or the claim was denied because you noted that the patient has a posterior septal deviation, which causes a physiologic functional impairment, then you may include the text below in your template letter: Septoplasty corrects deformities of the partition between the two sides of the nose. I am enclosing the previously submitted claim [or pre-certification request], the Explanation of Benefits and operative notes. Please reprocess this [claim] [pre-certification] for the payment of CPT code 30520. If you require additional information, please contact me at [Phone number]. Thank you for your prompt action. Sincerely, [Physician Name, MD] Enclosures: [insert number of enclosures] cc: [Patient’s Name]
If you receive a denial for a septoplasty from United Healthcare, report this denial and the denial reason to healthpolicy@entnet.org or 1-703-535-3727.
We encourage members to write us with relevant topics of interest in health policy and practice management. Please email us at healthpolicy@entnet.org.
[Insurer Name]
[Insurer Address]
Re: | Patient: | [Name] |
Policy Number: | ||
Group Number: | ||
Claim Number: | ||
Date of Service: |
Dear [Medical Director]:
Please consider this letter a formal request for reconsideration of a denial received for a septoplasty on [Patient’s Name] on [Date of Service] by [Name of Physician].
The [claim] [pre-certification] for the [septoplasty] was billed with CPT© code 30520 – Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft.
If the pre-certification or the claim was denied because the patient’s condition was not chronic for more than two months or the patient did not have recurrent acute sinusitis, then you may include the text below in your template letter:
I disagree with [insurer name]’s denial of the septoplasty based on your logic that the [Patient Name]’s condition was not chronic for over two months or that [s/he] did not have recurrent sinusitis. According to current medical practice, it is more clinically appropriate to document nasal obstruction that persists despite reasonable medical therapy (e.g., four to eight weeks). As a result, I believe that [insurer name]’s denial of this procedure is not justifiable.
If the pre-certification or the claim was denied because you did not include a photograph of the external nose, then you may include the text below in your template letter:
I disagree with [insurer name]’s denial of this septoplasty as medically unnecessary for [Patient Name] because I did not include a photograph of the patient’s external nose. Photographs will often not show a clinically significant septal deviation; only caudal deviations will be evident and photos generally demonstrate external nasal deformities. As such, I believe that [insurer name]’s denial of this procedure is not justifiable.
If the pre-certification or the claim was denied because you noted that the patient has a posterior septal deviation, which causes a physiologic functional impairment, then you may include the text below in your template letter:
Septoplasty corrects deformities of the partition between the two sides of the nose. I am enclosing the previously submitted claim [or pre-certification request], the Explanation of Benefits and operative notes.
Please reprocess this [claim] [pre-certification] for the payment of CPT code 30520. If you require additional information, please contact me at [Phone number].
Thank you for your prompt action.
Sincerely,
[Physician Name, MD]
Enclosures: [insert number of enclosures]
cc: [Patient’s Name]