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Carrier advocacy letters

SIR provides carrier advocacy letters to help you obtain prior authorization for your interventional radiology treatment or to appeal a denial of coverage.

Individual coverage request sample letters

The following are examples of a few common coverage request letters. The examples include letters for coverage for radiofrequency ablation of pulmonary tumor(s), MRI imaging of the uterus prior to uterine fibroid embolization, ovarian vein embolization for pelvic congestion syndrome, and prostatic artery embolization for benign prostatic hyperplasia. These templates include data, supporting evidence for the patient's needs, and can save you considerable work. Use these templates as guides when writing to carriers about certain treatments where reimbursement or a patient's coverage has been denied.

A sample template letter for unlisted codes: Unlisted CPT Code Template_v2.docx. For more sample template letters for other procedures, please see below.

Coverage letter templates

Percutaneous cryoablation of pulmonary tumors
MRI of the pelvis for UFE
Ovarian vein embolization to treat pelvic venous disease (pelvic congestion syndrome)
Prostatic artery embolization for benign prostatic hyperplasia
Varicocele/gonadal embolization treatment for males

How to use the templates

Download the letter.
Insert the information requested by the bracketed text. (Be sure to remove the brackets when you replace the placeholder text.)
Send a copy of the letter using the communication method preferred by your health insurance company.

Need help with your appeal?

SIR staff are available to assist you with crafting your letter to your insurance company to obtain coverage for your treatment. If a template does not yet exist for your treatment area, or you were denied coverage for your treatment, please fill out SIR's claim appeals form to submit your case to the team.

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