SAMPLE LETTER OF MEDICAL NECESSITY NEUROSTIMULATION Date: Inside Address Patient: Policy Holder: ID/Social Security #: Dear_____________, We are requesting predetermination of coverage/prior authorization for the implantation of a [Name of the Device] System on behalf of our patient, [Patient’s Name]. This device is for control of their chronic, intractable pain. Spinal cord neurostimulation electrically stimulates the spinal cord to superimpose paresthesia (tingling) over the areas of pain. The [Name of the Device] System consists of leads implanted near the levels of the spinal cord corresponding to the areas of pain and connected, via an extension, to a [Name of the Device] neurostimulator (power source that produces electrical pulses). We are requesting confirmation that this therapy be considered a covered benefit based on medical necessity and that associated professional fees for the surgery and follow-up will be covered. I request authorization for all costs associated with the screening test and possible subsequent implant procedure, including physician profession fees and facility fees. The charge for the device is usually included in the facility fees. The screening test and implant procedure will be scheduled at [Name of the clinic or facility] or some other eligible covered facility upon your confirmation. [Name of the Device] System is a neuromodulation pain treatment that uses epidural electrical stimulation to generate paresthesias (tingling sensations that interfere with the transmission of pain) within those body parts affected by severe pain. Neurostimulation therapy involves the implantation of a stimulating lead (electrode) near the spinal cord. This lead/electrode is connected to an internal power source that can be programmed to deliver a mild electrical current, which specifically targets that area of the spinal cord that innervates the painful body part in question. Only pain signals are blocked; normal sensation and motor function signals are left unaffected. This selective blockade is highly effective at reducing pain within a covered area by 50% or more. Neurostimulation therapy has been widely used since the 1970s to manage chronic pain. Neurostimulation Therapy does not damage the spinal cord or nerves and is “reversible” since it can be turned on/off; varied; reprogrammed; or even entirely removed. (Personalize the letter for the specific patient using the information outline that 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. 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 interventional efforts noting procedures, medications and/or therapies that have been previously rendered. Note the outcome of each. A timeline may be useful. Recommend Neurostimulator Note the benefits of the system, e.g., (Synergy) the ability to use two leads provide more stimulation options and flexibility in covering back or leg pain patterns. (If you are likely to implant only one lead at this time, state that the capability of independently controlling two leads may allow you to add a second lead at a future time to manage this patient’s condition.) State how this therapy is an appropriate intervention at this point in the patient’s care. Note therapeutic goals, anticipated outcome, risks of performing the procedure, risks of not performing the procedure, and possible complications. Describe the Implant Procedure Describe the surgery itself, listing anticipated procedure codes (CPT). Note the follow-up care associated with the therapy. This could be in an attachment rather than in the body of the letter itself. The acquisition cost of this device is significant. In order to protect the patient from unnecessary procedures, and in order to prevent resources from being ineffectively spent, I intend to perform a screening test beforehand. A screening test uses temporary materials, over three to ten days, in order to accurately recreate the effect of the permanent device. I can then determine and document the effectiveness of this type of therapy for [Patient’s Name]. If the screening test does not prove to be as effective as intended/desired; then the more costly permanent version will not be used. The results of the screening tests, and the documented failure of previous other types of therapy, I believe will confirm the medical necessity of this device. I ask that you concur with this rationale and consider the implantation of a Neurostimulator and its associated materials and services to be a covered benefit for [Patient’s Name]. I am enclosing a summary of procedures and dates of service that [Patient’s Name] has already undergone. I shall also enclose a relevant list of CPT codes and prices associated with completing both the screening tests and the permanent device implantation procedures. I would like to sincerely thank you for taking the time to review this information and for considering coverage. If you have any questions whatsoever, please feel free to contact me personally, so that I can be of further assistance.
Sincerely yours, ______________, MD
(This document is a template to be completed by Medtronic cutomers.)