REVIEW REQUEST FOR
Sacral Nerve Stimulation as a Treatment of Neurogenic
Bladder Secondary to Spinal Cord Injury
Provider Data Collection Tool Based on Medical Policy CG-SURG-08
Policy Last Review Date: 08/19/2010
Policy Effective Date: 10/13/2010
Provider Tool Effective Date: 03/28/2011
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 (ICD-9) 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
(e.g., Vocare Bladder System/FineTech Brindley Bladder Control System) to provide urination on demand and reduce postvoid 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):
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 Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
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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 Medical Policy CG-SURG-08
Policy Last Review Date: 08/19/2010
Policy Effective Date: 10/13/2010
Provider Tool Effective Date: 03/28/2011
_____________________________________________________________
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
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