REVIEW REQUEST FOR
Sacral Nerve Stimulation as a Treatment of Neurogenic
Bladder Secondary to Spinal Cord Injury
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-08
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 10/27/2010
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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Request is for the use of self-activated electrical stimulation of intact anterior sacral nerve roots using an implantable device
(for example, Vocare Bladder System/FineTech Brindley Bladder Control System) to provide urination on demand and
reduce post-void residual volume (if checked, please complete below):
Individual has a neurogenic bladder due to a clinically complete (American Spinal Injury Association) suprasacral
spinal cord lesion
Individual has an intact parasympathetic innervation of the bladder
Individual is skeletally mature & neurologically stable
Individual cannot be adequately managed with intermittent catheterization or condom catheterization.
Other: (please describe):
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REVIEW REQUEST FOR
Sacral Nerve Stimulation as a Treatment of Neurogenic
Bladder Secondary to Spinal Cord Injury
Provider Data Collection Tool Based on Clinical Guideline CG-SURG-08
Policy Last Review Date: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 10/27/2010
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 it’s
designee 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.
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