Key Resources for Prior Authorization and Appeal Requests for SpaceOAR® Hydrogel
Augmenix, Inc. and your dedicated Field Reimbursement Manager are committed to working with you (Provider and Facility) to navigate through the Payer Prior Authorization and Appeal processes, in order to achieve patient access for the SpaceOAR Hydrogel System.
Enclosed below, please find the recommended key supporting documents to assist you in the Prior Authorization or Appeal Process for SpaceOAR (CPT 55874).
In addition to including the patient medical records, patient lab reports and the key supporting documentation with each request, we have also enclosed a SAMPLE Template Payer Letters for customization. Please feel free to use these letters as a starting guide, to create one that works well for you – that you would be able to use as a “template” and then customize for each patient.
Recommended Paperwork for Prior Authorization and Appeal Requests for SpaceOAR hydrogel:
- Signed Letter of Medical Necessity/Prior Authorization/Appeal (explaining “why” the need for SpaceOAR, as well as a description of the technology)
- Detailed Patient Medical Documentation (H&P – History and Physical, etc.)
- Detailed Patient Lab Report
- SpaceOAR Supporting Clinical Documentation
- FDA Clearance Letter
- Clinical Publication Bibliography
- Mariados – Hydrogel Spacer Prospective study
- 3-Year Follow Up Publication (Hamstra, et al, Int’l J Rad Onc, 2016)
- 5-Year Follow Up Publication (Pinkawa, et al, Int’l J Rad Onc, 2017)
- ECRI Institute Health Technology Assessment (Member Access Only)
- NICE Interventional Procedures Guidelines
- NCCN Guideline Reference from February 2018 (page 31)
- ASTRO Support Statement
- ACR Support Statement
- 2018 AMA CPT Book excerpt of Category I CPT Code 55874 for SpaceOAR
- Instructions for Use
- SpaceOAR Sample Operative Note