Obtain prior authorization and cite supported codes

Prior authorization is required for devices and services listed in this policy; requests must reference the specific HCPCS/CPT codes for the device (e.g., A4595, E0744, E0745, E0764, E0770, 64555, 64561, 64590) and include documentation that demonstrates medical necessity for that device and code.

• Submit prior authorization using the specific HCPCS/CPT code(s) for the device or procedure.
• Include evidence in the request that the member meets the policy medical necessity criteria for the requested code.

Comply with applicable Medicare NCDs/LCDs

When a Medicare NCD or LCD applies to the requested device or service, follow the applicable NCD/LCD coverage rules and submit the documentation required by those determinations with the authorization or claim.

• NCDs/LCDs referenced include NCD 280.13, NCD 160.7, LCD L33802 and LCA A52520; follow these where applicable.
• Use the Medicare Coverage Database for current NCD/LCD details and required supporting documentation.

Require and document successful transcutaneous trial before implantation

Before implantation of a peripheral implanted nerve stimulator, submit documentation of a successful transcutaneous stimulation trial demonstrating at least 50% pain reduction for a minimum of 3 days.

• Document the trial result (≥50% pain reduction) and duration (minimum 3 days) in the prior authorization request.
• Ensure psychological evaluation and other listed pre-implantation criteria are also met for peripherally implanted stimulators.

Submit complete required documentation with requests

Include all required materials listed by the policy when submitting prior authorization or claims to avoid delays or denials.

• Ordering physician's chart notes
• Appropriate imaging studies or other diagnostic test results
• Documentation of conservative treatments trialed

Provide ordering physician notes, imaging, and conservative treatment history

Prior authorization requests must include the ordering physician's chart notes, appropriate imaging or diagnostic test results, and documentation of prior conservative treatment trials as specified in the policy.

• Chart notes from the ordering physician showing clinical indications and response to prior treatments.
• Relevant imaging or diagnostic test results (e.g., EMG, MRI) when objective evidence of pathology is required.

Align documentation with Medicare NCD/LCD requirements and appendix codes

When Medicare NCDs/LCDs are applicable, ensure submitted documentation aligns with those determinations and reference the applicable diagnosis codes from Appendix 1 when indicated.

• List applicable diagnosis codes from Appendix 1 on the request when following Medicare NCD/LCD guidance.
• Supply any additional documentation required by the referenced NCD/LCD.

Omitting required documentation may trigger denial

Failure to include the ordering physician's chart notes, appropriate imaging/diagnostic test results, and documentation of conservative treatments tried may result in denial of the prior authorization request.

• Omitting any of the required items listed in the policy is a trigger for denial.
• Provide clear documentation of conservative therapy trials to demonstrate medical necessity.

Risk of denial for noncompliance with NCDs/LCDs

Noncompliance with applicable Medicare NCDs/LCDs may lead to denial; coverage may be limited to indications specified in CMS policies or at the plan's discretion.

• If an NCD/LCD applies, failure to follow its rules and required documentation can result in denial.
• Additional indications outside NCD/LCDs may be considered only at plan discretion.

Include physician notes, imaging, and conservative treatment documentation with prior auth

Prior authorization submissions must include ordering physician notes, appropriate imaging/diagnostic studies, and documentation of conservative treatment trials as required by the policy.

• Ensure chart notes document the clinical indication and prior therapies attempted.
• Attach imaging or test results and records of conservative treatment attempts.

Submit documentation per NCD/LCD requirements when applicable

When Medicare NCDs/LCDs apply, submit the documentation required by those determinations; the plan may cover additional indications at its discretion but requires alignment with the NCD/LCD when applicable.

• Follow the NCD/LCD documentation requirements for Medicare Part B covered indications.
• Reference the applicable NCD/LCD documents (e.g., NCD 280.13, NCD 160.7, LCD L33802) on submissions.