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resection of the prostate (TURP) and now has recurrent symptoms. Given his age and prior surgical history, he and his urologist felt it was appropriate for him to undergo a prostate artery embolization (PAE) to alleviate symptoms, as this is a much less invasive option than TURP and does not require general anesthesia or an indwelling catheter in most cases.


The fact that I applied to have a hearing before an ALJ in the Office of Medicare Hearings and Appeals (OMHA) means that my first appeal was denied by the Medicare Administrative Contractor (MAC), and the reconsideration was denied by a Qualified Independent Contractor (QIC), so this was a third level appeal.


What was the experience like appealing to the judge? Dr. Uflacker: I applied for the appeal via mail, filling out a form that the patient’s MAC sent with the denial letter. The hearing was scheduled, and I phoned into the conference call with the judge. The entire thing took about 15–20 minutes. I was sworn in, and the testimony was recorded. The judge was friendly and pleasant, and very complementary of the presentation that I provided in support of the patient’s claim. The patient was also on the call and was also sworn in. The insurer, which was Humana in this case, waived their right to appear in the hearing and sent documentation in lieu of a representative.


Now that you know this is an option, will it impact how you approach Medicare denials in the future? Dr. Uflacker: I will add language noting that there is a legal precedent to this type of issue in my standard appeal letter that I send insurers in case of a denial. I will refer to this case in the letter and inform them that I am prepared to appeal to a Medicare ALJ in support of my patient’s right to receive their Medicare benefits for PAE, and any other


14 IRQ | FALL 2025


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procedure that should be reimbursed by a Medicare beneficiary. If this doesn’t resolve the appeal on the first or second rounds, then hopefully my (and other IRs’) future appearance before an ALJ will eventually lead to a change in the insurer’s reimbursement policy with respect to PAE and/or other procedures. This particular denial is foolhardy in my opinion, as it has been shown by more than one study that PAE is more economical than TURP in management of BPH, and that outcomes are similar.


Is there anything you’d advise for fellow IRs who may be appealing to a Medicare judge, in terms of expectations or preparations? Dr. Uflacker: Yes: be aware that your Medicare patient has the right to appear before an ALJ in case a second appeal is rejected by a QIC. The hearing was quick in my case and led to a “fully favorable” outcome, meaning that the ALJ issued


For more information on how to request an ALJ Hearing, visit the U.S. Department of Health and Human Services, Office of Medicare Hearings and Appeals website for frequently asked questions.


an order that Humana had to cover PAE for my patient.


Humana can appeal this decision in the Medicare Appeals Council Review, however. A search of ALJ appeals data showed that only about 20–30% of appeals receive fully favorable decisions, but this is heavily dependent on the ALJ and the particulars of the case. In my case, PAE has been reimbursed by almost all private payers and Medicare Administrative Contractors that I work with, and the evidence behind PAE is robust enough that it is now part of the standard of care.


Also be aware that MAC will provide “evidence” from contractors that are paid to generate “systematic reviews” that support the MAC’s position with regards to the reimbursement for a procedure or treatment. In my case, the denial letter cited the most recent American Urological Association guidelines, which actually state that PAE is an option for management of LUTS due to BPH. In addition, two contractors generated a report stating that PAE was inferior to gold standard options like TURP and that it was thus “investigational.”


It may be helpful if IRs could create a database of favorable precedent cases that can be cited in appeals letters. This could avoid a tertiary appeal and may contribute to a fully favorable decision, as legal precedent has an impact on a judge’s decision.


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