MAC00160-01, Rev. B; Sample Letter of Appeal for Insufficient Payment in the Hospital or ASC
[Date]
Re: [Insert Patient Name]
[Insert Claim #]
[Insert Patient ID #]
[Insert Patient DOB]
Dear [Payer Name]:
Thank you for the partial payment received on the above referenced claim for the prostatic urethral lift procedure
with the UroLift® System, billed with HCPCS codes {Choose either: ([C9739 or C9740] and L8699) or (52441 and
52442) under revenue codes 360 and 278, respectively. *Verify accuracy of coding and revenue codes* The
remittance notice advises that this claim was paid according to our contracted rates; however, the relevant coding
was not yet available when we negotiated our contracts, and [C9739 or C9740/52441 & 52442] should be a new
addition to our contract. The reimbursement received does not cover our costs for the permanent implants used in
this procedure, let alone other facility operating costs. The HCPCS codes C9739 and C9740, describing prostatic
urethral lift for symptomatic benign prostatic hyperplasia (BPH), were released by CMS on April 1, 2014 and track
to Medicare APCs 0162 and 1564 respectively.
I have provided an invoice which shows that each implant costs us $850. It was determined by his urologist that
Mr. [Patient’s name] required [X] implants because of his prostate volume and anatomy. With additional fees for
the scopes required to perform the procedure, the total invoice cost is $[enter dollar amount from relevant
invoice]. In addition to these direct device costs, we also have the costs associated with running the operating
room, anesthesia, surgical supplies, etc. as reflected on our initial claim.
The total requested reimbursement for the prostatic urethral lift procedure, including implants, is consistent with
other BPH treatment options we offer. As such, we are respectfully requesting that you reconsider your
reimbursement of this claim to be commensurate with the direct cost of the implants as well as our contracted
rates for comparable outpatient BPH procedures.
The UroLift® transprostatic implant system is indicated for the treatment of symptoms due to urinary outflow
obstruction secondary to BPH in men 50 years of age or older. Small permanent transprostatic implants are placed
cystoscopically to retract the obstructing prostatic lobes and hold open the urethra without requiring incision,
resection, or thermal ablation of the prostate. After applying transurethral local anesthetic, cystoscopy is
conducted to plan appropriate placement of the implants. The cystoscopy bridge is then replaced with the UroLift ®
delivery device housing a telescope and, after compressing the prostate lobe at the appropriate location, the
implant is deployed. The urethra is again cystoscopically examined to assess the effect and determine if more
implants are required. This process continues until a continuous channel is achieved through the prostatic urethra.
Typically four to six implants are required. A final cystoscopic view confirms the effect and inspects that all
implants are appropriately positioned. A typical transprostatic implant treatment lasts approximately 50-60
minutes. This implant procedure was completed successfully.
Thank you for your consideration. Please do not hesitate to contact me at [insert phone number] if I can further
assist you.
Sincerely,
[insert signature]
Enclosures:
Copy of UroLift® invoice
Copy of EOB/RA
UroLift® System product brochure