Urology Coding Alert

Dear Sir or Madam:

I am writing to request an expedited appeal of the denied preauthorization request for the prostate cancer treatment of [Patient Name].

It is my opinion that this procedure is medically necessary for the prostate cancer treatment for [Patient Name]. I recognize that stereotactic radiosurgery is not the primary treatment option for all prostate tumors. However, I would like you to consider the fact that stereotactic radiosurgery has been shown to be a valuable treatment option for patients who are poor surgical candidates or whose exact diagnosis deems them unfit for surgical resection. In my opinion, stereotactic radiosurgery is the most clinically appropriate treatment methodology in [Patient Name]'s case. This is because [Clinical Rationale]. Additionally, stereotactic radiosurgery avoids many of the potential risks and complications that are associated with other treatment options, is performed on an outpatient basis, and is more cost-effective than traditional surgery.

My treatment plan for [Patient Name] will be delivered using the CyberKnife stereotactic radiosurgery system in approximately [Number of fractions] sessions over [Number of days] days. This represents considerably lower human cost of treatment to [Patient Name] and considerably fewer healthcare resources, since traditional radiotherapy is routinely delivered in X to X sessions over a X to X week period.

The CyberKnife System is currently being used as monotherapy treatment for early-stage prostate cancer or as a boost following conventional radiation therapy in place of IMRT or brachytherapy. The CyberKnife System may reproduce the conformality for organ coverage achievable with brachytherapy or IMRT and can track and compensate for organ motion during treatment delivery. Because of similar conformality and dose fractionation, local control and complication rates are expected to be similar to HDR brachytherapy. A low ?/? ratio for prostate cancer indicates that a hypofractionated treatment regimen delivered via radiosurgery might be more effective than conventional external beam fractionation.

The CyberKnife System received FDA 510(k) clearance in 1999 to provide treatment planning and image-guided robotic radiosurgery for tumors in the head and neck. And in 2001, the CyberKnife System received 510(k) clearance to treat tumors anywhere in the body where radiation treatment is indicated. This procedure has been reimbursed by Medicare since January 2004, and therefore should not be considered "experimental" because the federal government does not provide coverage for experimental procedures.

Thus, coverage should be provided by [Insurance Company] for a delivery system that administers a traditional and well-recognized form of cancer treatment that can be of benefit to patient and insurer alike by virtue of the following:

• Highly accurate and precise radiation delivery to tumors

• Low incidence of procedure-related toxicity

• Improved efficiency of treatment

• Improved cost effectiveness.

Therefore, I respectfully request that I be allowed to perform what I consider to be the most appropriate and medically necessary treatment for the prostate cancer treatment of [Patient Name]. Due to the critical nature of this request, your immediate attention is greatly appreciated. Clinical articles have been included for your review and due-diligence process. Please contact me at [phone or e-mail address] if you require additional information.

Sincerely,