Date
Address
Address

RE: Urethral Bulking Agent with Macroplastique®, CPT® Code 51715

Patient Name:					Claim#
ID#						DOB

Dear Appeals Coordinator,

I received the above referenced explanation of benefits (EOB) from you dated [insert date] that I believe may be in error. The EOB regarding my patient [insert name] states that you are denying coverage for the urethral bulking agent treatment, CPT code 51715, that she had on [insert the date of service]. Your EOB claims this treatment has been found to be [add denial reason]. Based on the information in this letter, data provided and published clinical support I respectfully request that you reconsider your denial of urethral bulking.

Urethral bulking agents (UBAs), including Macroplastique, are approved by the Federal Food and Drug Administration for the treatment of female stress urinary incontinence (SUI) associated with intrinsic sphincter deficiency (ISD). UBAs continue to be a truly minimally invasive option for select women. 

Macroplastique is a UBA injected into the soft tissue surrounding the proximal urethra. The increased “bulk” allows the urethra to close more effectively, preventing unwanted and unexpected leaks.  Published evidence and my own clinical experience have demonstrated that Macroplastique is effective in significantly reducing symptoms of SUI associated with ISD. 

Macroplastique is a minimally invasive option for patients who can’t tolerate or accommodate a more invasive surgical intervention

[Patient Name] has suffered with the debilitating symptoms of [stress urinary incontinence, etc.] for [XX] years. Macroplastique was injected on [insert date(s)] and she has achieved marked improvement in her SUI episodes. As her physician I find UBA with Macroplastique to be medically necessary for this patient and request that you reconsider and reprocess this claim for payment. 

Sincerely,

Encl. 
•	Pertinent medical records
•	FDA approval letter
•	Clinical study