Sample Letter of Medical Necessity for Sacral Nerve Stimulation for Urinary
Control
This is a template for physicians’ offices to use in tailoring a letter for a specific patient.
Date:
Inside Address
Patient:
Policy Holder:
ID/Social Security #:
Dear __________,
This letter is to request a predetermination of coverage/prior authorization for test stimulation
and if improvement of symptoms is greater than fifty percent, implantation of a Medtronic
InterStim® System (sacral nerve stimulation) for Urinary Control in my patient
________________, who has [note the patient’s diagnosis here]. My patient has failed or could
not tolerate more conservative treatments. The CPT codes associated with this therapy include
64561, 64581, 64590, and 95972.
InterStim Therapy for Urinary Control is indicated for the treatment of urinary retention and the
symptoms of overactive bladder, including urinary urge incontinence and significant symptoms
of urgency-frequency alone or in combination, in patients who have failed or could not tolerate
more conservative treatments. Sacral nerve stimulation involves electrical stimulation of the
sacral nerves (in the lower region of the spine) via an implantable system that includes a lead,
neurostimulator, and in some models, an extension that connects the two. The therapy was
commercially released in the U.S. in 1997 for the treatment of urge incontinence in patients who
failed or could not tolerate more conservative treatments, and the indications have been expanded
since. In 2001, the FDA approved use of the implant lead with an externalized extension (Staged
Implant) as an additional test to determine whether a patient would benefit from the therapy.
With this therapy, test stimulation is done to determine whether the patient is likely to benefit
from the therapy. Test stimulation involves the placement of a lead connected to an external
power source for several days. This allows patients to temporarily experience stimulation and the
effect it has on controlling urinary symptoms and make an informed choice about the risks and
benefits of pursuing the therapy. Patients keep diaries of their voiding behavior for several days
prior to the test and during the test period. If the patient’s voiding behavior is significantly
improved and test stimulation is deemed successful, implant of the InterStim System may
proceed.
Based on my review, I believe ________________, is an excellent candidate for this therapy.
[Explain WHY the patient is an excellent candidate. Personalize the letter for the specific
patient using the information outline which follows. You may require one or more
paragraphs for each of the headings listed.]
Address each of the following points in the body of the letter or in an attached report:
Document Current Findings/Status
Describe the patient’s current status including diagnosis, complaints, and level of impairment.
Characterize the patient’s symptoms in terms of frequency and volume. Detail functional
impairments and state how quality of life, activities of daily living, caregiver (if applicable),
employment, etc. are affected.
Document Chronological History
Document the patient’s history of onset of symptoms, diagnostics and results, and interventional
efforts noting therapies/procedures and medications that have previously been attempted. Note
the outcome of each. A timeline may be useful.
Since ________________ fits the patient selection criteria and has not responded to other
measures, I recommend test stimulation for Medtronic InterStim Therapy for Urinary Control.
The decision to implant the InterStim System will be based on the patient’s response to the test
stimulation as indicated by significant improvement in urinary symptoms.
I request confirmation that this therapy is a covered benefit based on medical necessity, and that
associated professional fees for the test stimulation, surgery and follow-up will be covered. I
request authorization for all costs associated with this procedure including physician professional
fees and hospital fees. The charge for the device is included with the hospital fees. The test
stimulation procedure has been scheduled at [name of facility] on [date].
Thank you for your review of this information and for your coverage consideration. If you have
any questions, please contact me at [phone or email address].
Sincerely,
_______________, M.D.