MAC00160-01 Rev. A - Sample Letter of Appeal for Insufficient Payment in the
Hospital Outpatient 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
(PUL) procedure with the UroLift® System, billed with HCPCS codes [C9739 or C9740] and L8699 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] 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. As you
can see from the attached remittance advice, the reimbursement we received does not come close to
the Medicare unadjusted allowed amounts of $2007 and $4750, 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 (PUL) 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 five 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 [phone number] if I can
further assist you.
Sincerely,
[Physician Name]
Enclosures:
Copy of UroLift Invoice
Copy of EOB/RA
UroLift System Product Brochure