COOLIEF* may be covered by Medicare and by certain private payers. However, your doctor will need to confirm with your insurance provider if they cover the COOLIEF* procedure.

Chronic pain is different than regular pain. Usually the pain signal stops when the cause is resolved — for example, your body repairs the wound on your finger or your torn muscle. But with chronic pain, the nerve signals keep firing even after you’ve healed.

Your body keeps hurting weeks, months, or even years after the injury. Doctors often define chronic pain as any pain that lasts for 3 to 6 months or more.

Chronic pain can have real effects on your day-to-day life and your mental health. But you and your licensed healthcare professional can work together to treat it.

Prior authorization (sometimes called prior approval or precertification) is the determination of the medical necessity and appropriateness of a specific treatment as a requirement by your insurance provider. While prior authorization does not guarantee that the procedure is covered, if you don’t get preauthorization, you might not get reimbursed. If all the necessary information is submitted for review, the health plan will issue a prior authorization number. The process for getting prior authorization can average from five to thirty days.

Coverage of COOLIEF* varies by insurance plan, so contact your health plan provider and ask if they require prior authorization. If they do, your physician’s office may be able to assist you in the process.

Predetermination is a voluntary, written request for review of treatment or services, including ones that may be considered not medically necessary, investigational, experimental, or unproven. However, in this review process, your insurance benefit may be calculated before you have the procedure done and the costs may be more upfront. Unlike prior authorization, predetermination is offered by many health plans as an optional review process. Most predetermination requests take an average of 30–45 days to review.

Coverage of COOLIEF* varies by insurance plan, so contact your health plan provider and ask if they will provide a voluntary predetermination review. If they will, your licensed healthcare professional’s office may be able to assist you in the process.

Some commercial health insurance plans and Medicare or Medicare Advantage plans consider radiofrequency ablation procedures as medically necessary for the treatment of chronic pain. It is important that you and your health care provider check directly with your specific health plan for your plan’s benefits and ensure prior authorization prior to receiving the procedure when available.

Your plan may have a specific procedure for prior authorization of requested medical services. Typically, your health care provider will submit a letter of medical necessity explaining your specific clinical case. A plan may have one or two levels of appeal built within their process in the event that the initial request for authorization is denied.

A health plan should make available to you their policy and process for responding to appeals on a denied prior authorization request. A review by an external reviewer may be deemed as the definitive end step in the plan’s process. With the help of your physician you may be able to appeal this denial.

External reviews are usually part of a health plan’s established review process where a medical decision is rendered by a medical director who is different and independent from the individual who made the original decision.

Depending on who performed the independent review, your plan, and your state mandates, you may be able to bring your complaint to your State Department of Insurance or your company’s human resources department (for self-funded plans). Medicare and Medicare Advantage members have multiple appeal levels as defined by the Medicare & Medicare Advantage Grievances, Organization/Coverage Determinations and Appeals process.

There are numerous state and national patient advocacy groups that may be able to help you advocate for access to medical treatment for chronic conditions or you may wish to work directly with a patient advocate/case manager on a fee-for-service basis. Your physician may provide you with additional details.