Traditional Medicare carriers do not require prior authorization for the High Intensity Focused Ultrasound (HIFU) procedure.
Commercial & Medicare Advantage Plans
Many commercial insurance plans cover HIFU on a case-by-case basis. Prior authorization is recommended for all HIFU procedures. Contact your health plan to understand their prior authorization requirements before initiating treatment.
To assist your provider in the prior authorization process, Sonablate Corp. has sample letters of medical necessity (LOMN) and other supporting literature available. These documents are examples and should be customized to your specific clinical case by your physician. These documents will provide an example of the types of information and documentation required by health plans to determine coverage for the HIFU procedure. These sample documents are available in the Support Documents section. Always submit your prior authorization request in accordance with your health plan's process.
Private, Commercial Health Plans
Each private insurance plan will determine CPT or HCPCS code requirements for hospital outpatient or Ambulatory Surgery Center System claims. Whether billing CPT or HCPCS codes, private commercial health plans have proprietary facility fee schedules that may be based on a percentage of Medicare rates or negotiated contracts.
Denials & Appeals
If your prior authorization is denied, you have the right to appeal and should refer to your specific health plan for their appeal process. Your provider can appeal all denials on your behalf.
Sonablate Corp. has also developed a sample appeal letter that will assist your physician with your appeal letter development. The sample letters and other supporting documentation can be found in the Support Documents section.
Whether you receive a prior authorization denial, claim denial or insufficient payment, your physician can appeal on your behalf. The appeal process ensures that critical patient treatment decisions are given appropriate consideration. When appealing, please refer to and follow your health plan's defined appeal process.
Denials may be the result of the health plan not understanding the HIFU technology, or the submission requires additional information to help the health plan review your case. The health plan will review a variety of information, including medical records, published data and societal support. Your provider should always submit your appeal in accordance with the health plan's appeal timeline and process.