Practice resources


SIR offers tools and resources to help you thrive in your practice, enhance patient care and grow professionally. In this section of IRQ, get insight and learn from your colleague’s experiences!


Navigating claims


Appealing denials directly to a Medicare judge By Andre Uflacker, MD


A


re you aware of your right to appear before a Medicare Administrative Law Judge (ALJ) to


advocate for your patients?


According to the Centers for Medicare & Medicaid Services, if the Independent Review Entity denies a coverage appeal, any involved party may appeal this denial by requesting a hearing with an ALJ.


Many IRs may not know they have this option, unless notified by Medicare or told by physician colleagues. Andre Uflacker, MD, an independent IR in South Carolina, only became aware of this opportunity recently while navigating a denial appeal for a patient.


“I received a letter stating that they had denied my appeal, and that I had the option of appearing before a judge to argue why insurance should pay


for a PAE procedure,” he wrote on SIR Connect’s Open Forum.


Although other SIR members indicated that some version of this process has been available for decades, for Dr. Uflacker, it was a new opportunity— one he wants other IRs to be aware of.


IR Quarterly spoke to Dr. Uflacker about his experience, why this procedure was medically necessary for his patient and how this will impact his denial appeals process going forward.


Can you provide some context as to the procedure and why it was medically necessary for your patient? Andre Uflacker, MD: The patient is an 82-year-old man with severe lower urinary tract symptoms due to benign prostatic hyperplasia. He had undergone a previous transurethral needle ablation (TUNA) procedure and a transurethral


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