Pre-Authorization Form Instructional Letter

1 Pre-Authorization form Instructional Letter Neuromodulation Fax completed form to 1-877-835-2520. Dear Valued Boston Scientific Customer, Please use the attached Pre-Authorization form for submissions of Precision Plus Spinal Cord Stimulator (SCS). Pre-Authorization requests. The Pre-Authorization form provides you with an easy check-the-box format to help facilitate a quick and easy process. This form will provide us important patient and procedure information including diagnosis and procedure codes for SCS trial and permanent Pre-Authorization requests. The diagnosis code list is not an exhaustive list, but is a list of codes that relate to the indication statement below for the Precision SCS System.

2 SCS coverage criteria and diagnosis codes vary by payer, and it is always the physician's responsibility to determine appropriate diagnosis codes based on medical necessity. Boston Scientific does not guarantee reimbursement coverage and the ultimate responsibility for obtaining reimbursement rests with the provider. Instructions For Completing The Pre-Authorization form : Section 1 Please thoroughly complete each row in this section. Note: enter physician's NPI # and TIN#. Please check applicable box for the principal diagnosis (P) and any supporting secondary diagnosis (S) codes. Section 2.

3 If the principal diagnosis code is not listed, please write in the diagnosis in the other section. Section 3 Check applicable box(es) and enter number of units. Code L8680 is for per contact/ electrode. Check applicable box(es) and enter number of units. If revision, replacement or removal procedure please Section 4. specify the type of procedure in detail via the notes section. Physician must complete or review, sign and date the Pre-Authorization form . Clinical documentation ( , Section 5. treatment history & pysch. eval.) and patient insurance information must be included. Please fax completed Pre-Authorization form and all requested documentation information to 1-877-835-2520.

4 Should you have any questions, please call our Reimbursement Services Department at 1-866-287-0778. We are available to assist you Monday through Friday from 6:00am to 5:00pm, Pacific Time. Thank you! The PRECISION Spinal Cord Stimulator System (Precision System) is indicated as an aid in the management of chronic intractable pain of the trunk and/ or limbs, including unilateral or bilateral pain associated with the following: failed back surgery syndrome, intractable low back pain, and leg pain. Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies.

5 This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider's responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA- approved label.

6 Jan 2012_NM-50208-AA. **CONFIDENTIAL** Fax completed form and supporting clinical documentation to 1-877-835-2520 **CONFIDENTIAL**. Section 1 Pre-Authorization form Patient's Full Name: Patient's DOB: Physician Name: Name of Surgery Site: Surgery Date: State: NPI# TIN#. Site of Surgery: Physician Office ASC Outpatient Hospital Inpatient Hospital Procedure Type: Trial Permanent Implant Revision/ Replacement* Removal*. Section 2 Diagnosis Code Section Principal Diagnosis Code: Please indicate the principal (P) and secondary (S) diagnosis by checking the appropriate box: P = Principal and S = Secondary.

7 If the principal diagnosis code is not listed below, manually enter the code and description into the other section(s) at the bottom right of this Diagnosis Code Section. P S P S P S. Reflex sympathetic dystrophy, Thoracic or lumbar spondylosis with Thoracic or lumbosacral neuritis or unspecified myelopathy, thoracic region radiculitis, unspecified Reflex sympathetic dystrophy of the Thoracic or lumbar spondylosis with Neuralgia, neuritis, and radiculitis, lower limb myelopathy, lumbar region unspecified Reflex sympathetic dystrophy of Lumbar intervertebral disc without Pain in limb other specified site myelopathy Lumbar or lumbosacral intervertebral Chronic pain Acquired spondylolisthesis disc Intervertebral disc disorder with Injury to nerve roots and spinal Chronic pain due to trauma myelopathy, lumber region plexus, dorsal root Postlaminectomy syndrome, lumbar Injury to nerve roots and spinal Other chronic postoperative pain region plexus, lumbar root Spinal stenosis, other than cervical/.

8 Other chronic pain Other: unspecified region Spinal stenosis, other than cervical/. Causalgia of lower limb Other: throacic region Mononeuritis of lower limb, Spinal stenosis, other than cervical/. Other: unspecified Lumbar region Mononeuritis of unspecified site Lumbago Other: Lumbosacral spondylosis without Sciatica Other: myelopathy Physician's Order: Check the box (es) for services & supplies rendered: Section 3 Trial Procedure1. CPT Code Description Units Code Description Units 63650 Implant neuroelectrodes L8680 Implt neurostim elctr each 95972 Analyze neurostim L8699 Prosthetic implant NOS.

9 95973 Analyze neurostim Imp/rep/spine stim lead Other: _____ Other: _____. Section 4 Permanent Implant Procedure1. CPT Code Description Units Code Description Units 63650 Implant neuroelectrodes L8687 Implt nrostm pls gen dua rec 63655 Implant neuroelectrodes L8680 Implt neurostim elctr each 63685 Insrt/redo spine n generator L8699 Prosthetic implant NOS. 95972 Analyze neurostim Imp/rep/spine stim lead 95973 Analyze neurostim Ins/rep 2 pul gen, rechrg Other: _____ Other: _____. Other: _____ Other: _____. 1. CPT Copyright 2010 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association.

10 Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA. does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Notes Section (If revision, replacement or removal please describe intended procedure*): Section 5 Physician Certification Section By signing below, I certify that (1) I am the physician identified in the first section of this document, (2) I have completed this document in its entirety (or reviewed it carefully after it was completed by an employee under my direction), and (3) all the information provided by me or my staff, including the patient diagnosis codes selected and medical documentation supporting the procedure is true, accurate, and complete to the best of my knowledge.