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Essential Components of a Pre-Determination Request To the insurance company for coverage

As part of the pre-determination request, it is very important that your doctor makes a strong argument for why the service or procedure is necessary.  The following information should be included in the pre-determination request:

  • Records proving the disease severity,
  • current treatment options that have been tried and have failed,
  • and records showing healthcare use (medicines, ER visits, hospitalizations, etc.) as a result of failed attempts with the standard of care (the asthma guidelines).  

Bronchial Thermoplasty Procedure Example

Specifically, for the bronchial thermoplasty procedure, key elements to support a pre-determination request are a correct diagnosis, use of best available care for a reasonable period of time and evidence that these medicines are still not working:

  1. Severe persistent asthma diagnosis (i.e. rule out other diagnoses)

  2. Detailed list of current controller medicines (documents showing the need for ICS and LABA combination and/or maintenance oral corticosteroids, or other controller medicines such as Xolair, leukotriene modifiers, theophylline, or anti-cholinergics to manage asthma) and proof the patient is taking medicines as prescribed by the doctor

  3. Asthma is not well controlled, despite taking medicines as prescribed by the doctor

  4. Respiratory related exacerbations (requiring oral corticosteroids), emergency room visits, and hospital admissions in past 12 months and/or use of short-acting beta-agonists

  5. List of other health conditions and proof that these are not exacerbating asthma

 

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