Attn: Director of Claims



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Date conversion03.12.2016
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Attn: Director of Claims

Insurance company name

Insurance company address

Re: Claim #:

Patient Name

Patient’s ID #:

Dates of Service:

Total Billed Amount:


Dear [insert Medical Director’s name]:
This letter is a formal request for reconsideration of a denial of claim [insert claim number] for patient [insert patient’s name]. The procedure was billed with CPT code 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure).
Attached is a copy of the operative note in which [insert doctor’s name] states the primary procedure was performed using the operating microscope. The procedure required the additional, fine-detail visualization provided by the operating microscope. According to the CPT coding instruction for 69990, the use of the operating microscope is not included in the primary procedure code [list code] we billed. CPT 69990 is also an add-on code; therefore, modifier -51 [multiple procedures] is not required. The fee schedule relative value for code 69990 already takes into account the fact that this procedure is never performed alone. Therefore, we believe it should be separately reimbursed at the full allowable rate.
I am attaching the CMS-1500 claim form, the explanation of benefits (EOB) showing the inappropriate denial, and the operative note reflecting use of the operating microscope.
Please reprocess this claim for payment of CPT code 69990. Thank you for your prompt attention.
Sincerely,

[insert doctor’s name]



Enclosures: [insert number of enclosed documents]

cc: [insert patient’s name]


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