Transcription of Implanted Electrical Stimulator for Spinal Cord ...
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Implanted Electrical Stimulator for Spinal Cord ...
Impla nted Electr ica l Stimula tor for Spina l Cor d Page 1 of 4 UnitedHea lthca r e Commer cia l Medica l Policy Effective 11/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Commercial Med i ca l P ol i cy Implanted Electrical Stimulator for Spinal cord Policy Number: 2021T0567R Effective Date: Nov e mber 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Documentation 1 Applicable Codes .. 3 Food and Drug Administration .. 3 Policy History/Revision 4 Instructions for Use .. 4 Coverage Rationale Implanted Electrical Spinal cord stimulators, including high-frequency Spinal cord stimulators and burst Spinal cord stimulators are proven and medically necessary for treating the following indications: Complex regional pain syndrome (CRPS) Failed back surgery syndrome Implanted Electrical Spinal cord stimulators are unproven and not medically necessary for treating the following indicatio
BurstDR spinal cord stimulators) Lead placement locatoi n o Thoracic o Lumbar • Indicate if this request is for a trial or permanent placement o For permanent placement, include documentation of at least 50% pain relief with temporary implant • Operative notes from the spinal cord stimulatory trial • Clinical notes including :
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