UHC CO-197 Prior Authorization Denials in Pain Management

[Practice Letterhead]
[Date]

UnitedHealthcare Provider Appeals
PO Box 30432
Salt Lake City, UT 84130

Re: Appeal of CO-197 Denial
Member: [Patient Name]
Member ID: [Member ID]
Date of Service: [DOS]
Claim Number: [Claim #]
CPT: [e.g., 64483 - Transforaminal epidural, lumbar, single level]
Spinal Level: [e.g., L4-L5]

To Whom It May Concern:

We are formally appealing the CO-197 prior-authorization denial for the above-referenced pain-management procedure. The service was medically necessary under UHC's pain management medical policy and supported by documentation of failed conservative care.

Clinical Summary:
Patient with [diagnosis, e.g., lumbar radiculopathy, M54.16] failed conservative management consisting of [specifics, physical therapy X weeks, NSAIDs, activity modification] over [duration]. MRI dated [date] demonstrates [finding correlating with symptoms]. Patient's pre-injection pain score was [X/10] with [functional limitation].

Documentation attached:
1. MRI report confirming anatomic correlate to pain
2. Physical therapy notes demonstrating failed conservative trial
3. Medication trial documentation
4. [For repeat injection] Prior injection response log: X percent relief for Y weeks, pain score change, functional improvement
5. Retroactive authorization request submitted [date]

The precertification gap was administrative. Clinical medical necessity is clearly met under UHC's interventional pain medicine policy. We respectfully request approval of the retroactive auth and reprocessing of the claim.

[Dr. Name], the performing interventional pain physician, is available for peer-to-peer review at [phone].

Sincerely,
[Name, title]
[Practice]