Letter Template for reimbursement after FLA prostate 1
To Whom It May Concern:
1)Acknowledge that you are complying with the insurance company rules by filling out the required forms
2)Describe what procedure was done and for what reason
3)Briefly describe FLA
- Who did it and what is his experience—include a short biography and literature reference for the performing physician
- What system was used (visualase) and is it FDA approved? (Yes, in 2007, #K071328)
4)What is laser used for medically and why is it good therapy for prostate cancer (laser ablates tissue in a very precise way, avoids side effects of prostate surgery or radiation, and allows the patient to return to work in 1-2 days)
5)The medical use of lasers began many years ago and has a proven record of success in treating skin conditions, epilepsy (brain ablations), vascular problems and tumors.
My Disease History
1)Fill in regarding your personal experience with the diagnosis of prostate cancer
Options presented and why I chose FLA
1)Describe what you were offered and what the expected side effects would be. Were you comfortable with watchful waiting or active surveillance?
2)Why you chose FLA and the medical and personal reasons to do so
3)Describe how FLA was done as an outpatient on one day with no side effects and back to work immediately (this focuses on the reduced cost of FLA)
4)Mention that surgery/radiation is very expensive and you paid much less out of pocket for a safer procedure with good results thus far
Follow-Up History Summary
1)Discuss how things have gone with you after the FLA. PSA dropped, no side effects, MRI shows no disease, etc.
2)This is where you should put 6 month and 1 year follow up data.
Summation
1)Sum up all the above. FLA is less expensive, less disruptive, and more applicable to you because you have low to intermediate risk disease confined to the prostate and determined that focal therapy was in your best interest and has, thus far, proven to be successful. Indicate that, in your belief, FLA was a reasonable and necessary treatment for your condition and was performed by a practitioner with adequate training and experience in the management of men with prostate cancer.
Sincerely,
XXXXXXXXX
Attached Documents
Add documents to support your claim.
1)Insurance forms
2)Itemized payments
3)CMS coverage determination regarding laser (140.5 LCD form)
4)Dictations for MRI prostate and MRI ablation/biopsy
5)Dr. Walser’s bio/experience
6)Visualase FDA clearance letter
#’s 3, 5, and 6 are available on our web site
Your MRI prostate imaging/biopsy/ablation reports (if done at UTMB) are available at
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