One Appeal Per Payer That Denies Your Device. From the Payer's Own Policy.
The policy says investigational. The office gets the denial. Nobody writes the argument.
We write it. For each payer that denies your code, one appeal built from that payer's current policy text, the evidence the policy itself cites, the FDA authorization and a measured plan that closes the gaps the policy names. The office fills in the patient and sends. The kit re-issues when the policy changes.
See what is in the kit- No patient data
- No BAA
- No charge
- No pitch
The denial rides on your code. The appeal is somebody else's job.
A commercial payer writes a policy. It lists your CPT or HCPCS code and calls the procedure or device investigational, experimental, unproven or not medically necessary. From that day every claim with your code starts with a denial.
The denial lands at the surgeon's office or the DME supplier, not at your company. Their appeals team, if there is one, does not know your evidence. The letter that goes back, when one goes back at all, is a template that does not answer the policy. Your market access team can see the policy change the week it happens and still has no way to put the argument into the hands of the person who sends the appeal.
The coverage maps show the shape of it. On CPT 27278, most payers cover the procedure and deny only the device. On CPT 15011-15018, one payer covers the burn indication with criteria and six call it investigational. On E0738, every policy that names the code calls it investigational. Each of those positions has a text behind it, and the text is public.
One letter per denying payer. Written from their text, not ours.
For one code family, the kit holds a coverage map and one appeal for every payer on it that denies. Every letter follows the same seven steps, and every step cites the payer's own document.
- 1. What the policy concedes. Where the payer's own rationale accepts a treatment effect, the letter quotes it. The denial then rests on evidence gaps, not on absence of benefit, and the letter says so.
- 2. The patient matched to the evidence the payer cites. The trial in the policy becomes a checklist in brackets: diagnosis, duration, prior therapy, plateau. The office fills it in.
- 3. Real-world data the policy itself cites. Only what the payer has already read. Nothing the payer has not seen is presented as settled.
- 4. The FDA authorization. De Novo, PMA or 510(k), with the number, as the maker states it.
- 5. The gaps the policy names, closed for this patient. One course with objective re-assessment at set points, continued only if the patient responds. The payer gets the member-level data it says is missing.
- 6. No equal alternative. Why the covered option is not right for this patient, in the treating physician's words.
- 7. The request ladder. Reverse the denial; else a peer-to-peer review; else a benefit exception for individual consideration; else external review under state law, with the deadline.
Start With One Denial. No Patient Data.
Before anyone talks about a kit, read one letter against one real denial.
- 1Send payer, code and denial reasonThe denial reason as the payer wrote it, in the app or by email. No names, no member IDs, no dates of service. The form refuses them.
- 2We draft from the payer's own policyThe version in force on the denial date. Every cited line is checked against the passage it cites. The draft comes back within 24 hours.
- 3You judge it against what the office sends todayIf it is not better, you have lost ten minutes and we will say so. If it is, the kit is that letter for every payer on your coverage map.
The letter moves when the text moves.
Payers revise these policies on their own schedule and send no notice. We re-read every policy in a kit on a fixed cadence and keep every version with its effective date. When a text changes, the letters that cite it are marked stale and re-issued, and the kit shows the date the policy changed and the date the letter was re-issued.
A letter that was sent keeps citing what it cited. A revision is a new version, never an overwrite, so an appeal sent last month still matches the policy it answered.
If your team already subscribes to a policy alert service, keep it. The alert tells you the text changed. The kit is the argument against the new text.
What We Never Do
Each line is a rule, not a preference.
Never
- Take a fee that depends on what is recovered, on an approval or on device volume. The fee is flat and fixed in writing.
- Pay a provider, or ask a provider to pay us for the kit. The maker pays; the office receives a letter.
- Accept patient data by email. A file with patient data in it is deleted unopened, and we confirm the deletion in writing.
- Reproduce AMA CPT descriptor text. The kit quotes the payer's own words and lists codes.
- Send anything to a payer. The office approves and sends every appeal.
Who Sees Patient Data
- In the kit: nobody at AppealHound. The letter carries brackets, the office fills them in.
- In the one-denial run: nobody. The form refuses names, member IDs and dates of service.
- If a maker later asks us to draft real appeals for its offices, that is separate work under a signed BAA, with data held only on our US infrastructure and every access logged.
- The maker never sees its customers' patient data through us.
Your Questions Answered
Is this a kickback risk for a device maker?
The fee is flat and fixed in writing. It does not depend on an approval, on what is recovered or on device volume, and nothing is paid to a provider. The office receives a letter it approves and sends itself. Counsel reviews the arrangement before the first agreement.
Is the kit HIPAA-covered work?
The kit holds no patient data. Each letter carries brackets for the patient facts and the office fills them in. So there is no BAA for the kit or the one-denial run. If a maker later asks us to draft real appeals for its offices, that is separate work under a signed BAA, with patient data held only on our US infrastructure.
We already subscribe to payer policy alerts. What is different?
An alert tells you the text changed. The kit is the argument against that text, one letter per denying payer, and it is re-issued when the text moves, with the date it moved.
Who sends the appeal?
The physician office. A person there approves the letter and sends it on the office's letterhead. Nothing goes to a payer without that approval, and we never contact patients.
How does the kit reach the offices?
As plain text and PDF per payer, which your reimbursement team or field team hands to the office, and as sign-in access for the office under your account. Either way the office fills in the patient and sends.
Do you have every payer's policy?
No. We read the payer's published policy where it is public and say so where it is not. Each coverage map lists the payers that could not be verified rather than guess a stance.
Do you claim a win rate?
No. We ask every office for the outcome of every letter and will publish rates by payer and code, with the denominator, when there are enough to mean something. Until then we claim nothing.
What does it cost?
Start with one denial, free: payer, code and the denial reason, no patient data. The appeal kit has a flat fee, named on the first call. It never depends on what is recovered.
Send One Denied Claim. Read What Comes Back.
The appeal, written from that payer's own policy, within 24 hours.
Payer, code and the denial reason. No patient data, so nothing to sign first.
Or email malte@appealhound.com with the three lines.