Example of Pre-Authorization Letter for Spinal Cord Stimulation

Patient:

Dear Mr. ----:

 

This letter is to request a predetermination of coverage/prior authorization for the implantation of a Medtronic Spinal Cord Stimulator System for the control of chronic pain. Spinal cord stimulation therapy is a neurostimulation pain therapy that uses epidural electrical stimulation to generate paresthesia (tingling) in the area(s) of pain. It involves the implantation of a stimulating lead(s) near the spinal cord. The lead is connected to an implantable neurostimulator.

 

Spinal cord stimulation therapy does not damage the spinal cord or nerves and is considered to be a “reversible” therapy. The success of the therapy can be assessed with a screening test prior to system implant.

 

Spinal cord stimulation therapy should not be confused with transcutaneous electrical nerve stimulation (TENS), which have no implantable components and acts only in the periphery. Spinal cord stimulation therapy has been widely used since the 1970s. I have enclosed further information about this therapy and summaries of clinical studies.

Based on my review, I believe that my patient, -----, is an excellent candidate for this therapy. Her pain began in (Date), following a work related injury. She describes the pain as constant, radiating down the right leg, associated with tingling, and burning. She also describes the pain as stabbing and throbbing and wakes her at night. The pain sometimes makes her depressed and expresses her pain is distressing to severe. She rates her pain as a VAS of 7/10 at present. She feels she is only functioning at a 40% level and believes she was at 100% functional before her work related injury. Her pain is made worse by walking, lifting, bending, weather/temperature changes, standing and sitting. The pain is only moderately relieved by lying down.

 

During the past month, the pain has interfered extremely with her job, performing household chores, yard work, as well as, shopping, socializing with friends, recreation and hobbies, having sexual relationships and physical exercise. The pain has interfered quite a bit with her sleep and a little bit with her appetite. The pain has left her not able to function in a normal job. Pain has affected her sleep, activities, work, relationships and finances. She has tried surgery, nerve blocks, Behavior modification, physical therapy and biofeedback/relaxation therapy. She has undergone several epidural steroid injections to help with her pain, only with mild improvement in her symptoms. She has undergone as extremely complex spine surgery on February 5, 2003 , including anterior lumbar re-do decompressive discectomy, partial corpectomy, reduction of retrolisthesis fusion, stabilization procedure at L5-S1 level. Her diagnosis includes the following:

  1. S/P anterior lumbar redo-decompression, reduction of retorlisthsis, fusion stabilization procedure at L5-S1 level.
  2. MRI showing moderate disogenic disease at L5-S1.
  3. Recurrent debilitating back and leg pain symptomatologies.
  4. Apparent inability to undergo functional rehab at a pain program.
  5. Concerns about possible RSD type abnormalities of the RLE in regards to etiology of further pain difficulties.
  6. S/P Rt. L5-S1 lumbar microdiscectomy decompression foraminectomy.
  7. Central, Rt. Paracentral lumbar disc herniation L5-S1.
  8. Persistent debilitating Rt. S-1, somewhat L5 lumbar radiculopathy.
  9. Central and somewhat R>L paracentral lumbar disc heriation subligamentous L5-S1 level.
  10. Perineural sacral root cysts and the S1, S2 and S3 level.
  11. Severe persistent and overall worsening work related lumbar/lumoscaral strain.
  12. Rt. S-1, somewhat L-5 distribution, lumbar radiculopathy with complaints of severe pain.
  13. Prior radiographic evidence of mild disogenic disease and difficult disc protrusion L4-5 level.
  14. Prior radiographic evidence of mild disogenic disease and small central disc herniation at L5-S1 level.
  15. Current severe symptom worsening after reported epidural steroid injection.

 

 

Because ------fits the patient selection criteria and has not responded to other measures, I recommend a screening test with neurostimulation. The decision to implant the Medtronic Spinal Cord Stimulation System will be based on the patient's positive response to the screening test as indicated by a significant decrease in pain and an improvement in function.

 

I request confirmation that this therapy is 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 professional fees and facility fee. The charge for the device is included with the facility fees. The screening test will be n scheduled at ----- hospital as soon as we have authorization from you. The implant procedure will be tentatively scheduled at the same facility approximately two weeks after the trial and based upon the success of the trial.

 

Thank you for your review of this information and for your coverage consideration. If you have any questions, please contact me.

 

Sincerely,