REVIEW REQUEST FOR
Implanted (Epidural & Subcutaneous)
Spinal Cord Stimulators (SCS)
Provider Data Collection Tool Based on Medical Policy SURG.00060
Policy Last Review Date: 11/05/2015
Policy Effective Date: 01/01/2016
Provider Tool Effective Date: 12/12/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) ( if known):
This medical policy based data collection tool is for medical necessity review request for the use of
implantable neurostimulation techniques including spinal cord stimulators and subcutaneous target
stimulation (also known as peripheral subcutaneous field stimulation).
Please check all that apply to the individual:
Request is for a temporarily implanted epidural spinal cord stimulator for treatment of chronic (greater than 6 month
duration) intractable neuropathic pain
There is documentation in the medical record of the failure of 6 months of conservative treatment modalities
(pharmacologic, surgical, psychologic or physical), if appropriate and not contraindicated
Further surgical intervention is not indicated
Psychological evaluation has been obtained and there is documentation that there are no inadequately controlled
mental health problems (including but not limited to alcohol or drug dependence, depression, or psychogenic pain)
There are no contraindications to implantation such as sepsis or coagulopathy
There is objective documentation of pathology in the medical record
Request is for a permanently implanted epidural spinal cord stimulator for treatment of chronic (greater than 6 month
duration) intractable neuropathic pain
There has been a successful temporary trial of spinal cord stimulation
Individual had a 50% reduction in pain for at least 2 days
Improvement in function during the trial is documented in the medical record
The permanent electrodes are placed in the same spinal region(s) where the temporary trial produced relief
Request is for a temporary implantable subcutaneous target stimulator device
Request is for a permanent implantable subcutaneous target stimulator device
Request is for treatment of thalamic pain syndromes by an implanted epidural spinal cord stimulator
REVIEW REQUEST FOR
Implanted (Epidural & Subcutaneous)
Spinal Cord Stimulators (SCS)
Provider Data Collection Tool Based on Medical Policy SURG.00060
Policy Last Review Date: 11/05/2015
Policy Effective Date: 01/01/2016
Provider Tool Effective Date: 12/12/2015
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.