Authorization Process

Prior to starting CyberKnife treatment, the doctor or reimbursement administrator will investigate whether treatment is covered.

If the patient is covered by a private payer or Medicare Advantage plan, the center may seek a prior authorization.

If the patient is covered by traditional Medicare Parts A or B, prior authorization is not required and coverage is generally provided for a broader range of indications; nonetheless, treatment usually follows guidelines or a published coverage policy found on the Medicare Administrative Contractor website.

If no policy exists or the policy has been retired, the center may make treatment decisions based on medical necessity.

During this part of the process, your role is minimal. If the center determines you are eligible for coverage, your center will contact you for scheduling to initiate treatment.

If your insurance carrier is not one with which the center is familiar, you may be asked to contact your carrier directly to assess whether your condition is covered for CyberKnife treatment.

If the CyberKnife treatment is denied, the doctor will typically engage in a peer-to-peer conversation or draft a letter to the payer, which describes why the CyberKnife treatment is appropriate and medically necessary in your specific case. The payer may review the letter and decide to authorize payment for the CyberKnife treatment, informing the doctor’s office or reimbursement administrator of the approval. Or, the payer could again deny your eligibility, after which you have the right to appeal the decision.

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Authorization Process
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