№ files_lp_4_process_3_129192
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Administrative healthcare authorization form used by providers to submit patient information, diagnosis codes, and procedure coding for insurer pre-approval of spinal cord stimulation procedures associated with Boston Scientific devices.
Organization:
Boston Scientific Corporation
Document Type:
Pre-Authorization Form
Medical Field:
Neuromodulation / Spinal Cord Stimulation
Purpose:
Insurance pre-authorization request for spinal cord stimulation procedures
Applicable Procedures:
SCS Trial, SCS Implant, Revision, Replacement, Removal
Coding Systems Referenced:
CPT®, ICD
Procedure Codes Included:
63650, 63655, 63685, 63661, 63662, 63663, 63664, 63688, 95971, 95972
Regulatory References:
FDA labeling, Medicare NCD and LCD requirements
Intended Users:
Physicians and healthcare providers submitting authorization requests
Required Information:
Patient information, insurance details, physician and facility identification, diagnosis codes, procedure codes and units
Certification Requirement:
Physician attestation of medical necessity and accuracy of submitted information
Confidentiality Notice:
Confidential clinical and patient information transmission via fax or email
Contact Information:
[email protected]
Note:
; Fax 1-877-835-2520; Phone 1-866-287-0778
Copyright:
© 2021 Boston Scientific Corporation and its affiliates
Trademark Notice:
CPT® registered trademark of the American Medical Association
Document Identifier:
NM-68609-AH
Price: 8 / 10 USD
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The product description is provided for reference. Actual content and formatting may differ slightly.
Year:
2026
Region / City:
San Diego, California
Document Type:
Pre-authorization form
Institution:
San Diego Public Sector
Target Audience:
Psychologists and healthcare providers
Purpose:
Request prior approval for psychological testing under Medi-Cal
Required Information:
Client details, psychologist credentials, testing dates, diagnostic information, tests and CPT codes
Processing Time:
14 calendar days from receipt
Referral Source:
Child Welfare Services or court-ordered referrals
Clinical Context:
Includes case background, purpose of testing, and relevant medical/psychiatric history
Limitations:
Psychological testing, test administration, and scoring hours cannot exceed 11 hours total
Fax Number:
(866) 220-4495
Phone for Questions:
(800) 798-2254 Option #3 then Option #4
Pre-authorization Requirement:
Yes
Year:
2021
Region / City:
Not specified
Topic:
Clinical practice guidelines, rehabilitation, stroke
Document Type:
Interview transcript
Organization / Institution:
Academy of Neurologic Physical Therapy, Jefferson College of Rehabilitation Sciences, Boston University
Authors:
Dr. Therese Johnston, Dr. Lisa Brown
Target Audience:
Clinicians, rehabilitation professionals, researchers
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2022
Region / City:
United States
Topic:
Medical necessity, prior authorization, spinal cord stimulation
Document Type:
Template letter
Organization / Institution:
Abbott
Author:
Not specified
Target Audience:
Healthcare providers, insurance companies
Period of validity:
Not specified
Approval date:
Not specified
Amendment date:
Not specified
Jurisdiction:
United States
Regulatory framework:
40 CFR Part 146
Program:
Class VI Underground Injection Control
Agency:
U.S. Environmental Protection Agency
Document type:
Regulatory guidance template
Subject:
Stimulation activities for Class VI injection wells
Notice requirement:
30-day advance submission to the Director
Approval authority:
EPA
Applicable activities:
Injection well stimulation to enhance injectivity
Context:
Federal requirements and recommendations for stimulation planning
Year:
2023
Region / City:
Canberra
Topic:
Neurological Rehabilitation
Document Type:
Clinical Procedure
Organization:
Canberra Health Services
Author:
Not specified
Target Audience:
Healthcare professionals (Occupational Therapists, Physiotherapists, Allied Health Assistants)
Period of Validity:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2017–2021
Medical field:
Sleep medicine
Condition:
Moderate to severe obstructive sleep apnea
Intervention:
Hypoglossal nerve stimulation
Procedure codes:
64582, 64583, 64584
Type of document:
Evidence review and policy summary
Reviewing bodies:
NICE; VbBS; HERC
Last review date:
November 2021
Study types included:
Systematic review; randomized controlled trial; prospective and retrospective case series
Number of studies:
7
Total patients:
326
Geographic context:
United Kingdom; United States
Regulatory context:
Clinical governance and payer policy assessment
Year:
2017
Region / City:
Amsterdam, The Netherlands
Subject:
Alcohol addiction, Cognitive Bias Modification (CBM), transcranial direct current stimulation (tDCS)
Document Type:
Research Article
Author:
Tess E. den Uyl, Thomas E. Gladwin, Mike Rinck, Johannes Lindenmeyer, Reinout W. Wiers
Target Audience:
Researchers, clinicians, and professionals in addiction and neuromodulation
Period of Action:
2017
Approval Date:
N/A
Date of Changes:
N/A
Year:
2024
Region / City:
Hyderabad, Pakistan
Subject:
Stroke Rehabilitation
Document Type:
Original Research
Author:
Mehreen Niaz, Fozia Baloch, Asma Bilal, Prem Sagar, Nadeem Memon
Target Audience:
Physical Therapists, Healthcare Professionals in Stroke Rehabilitation
Period of Action:
2024
Approval Date:
15-02-2024
Revision Date:
10-02-2024
Date of Submission:
05-12-2023
Date of Online Publishing:
08-03-2024
Date of Print:
31-3-2024
DOI:
10.36552/pjns.v28i1.957
Year:
Not specified
Region / City:
Not specified
Subject:
Medical procedure safety
Document Type:
Checklist
Organization / Institution:
Not specified
Author:
Not specified
Target Audience:
Healthcare professionals
Effective Period:
Not specified
Approval Date:
Not specified
Date of Amendments:
Not specified
Year:
2019
Region / City:
International
Topic:
Dorsal Root Ganglion Stimulation, Pain Management
Document Type:
Research Paper
Organization / Institution:
Multiple Academic Institutions
Authors:
Esposito MF, Malayil R, Hanes M, Deer T, Liem L, Russo M, Huygen FJ, Van Buyten JP, Smet I, Verrills P, Cousins M, Brooker C, Levy R, Kramer J, Eldabe S, Espinet A, Wahlstedt A, Kang P, Patel NK, Vesper J, Kimber A, Cusack W, Hunter CW, Yang A, Chapman KB, Mogilner AY, Yang AH, Yadav A, Patel KV, Lubenow T, van Helmond N, Kallewaard JW
Target Audience:
Medical Researchers, Pain Management Professionals
Period of Action:
2011-2019
Approval Date:
2011 (EU, Australia), 2016 (FDA)
Date of Changes:
2019
Note:
Description
Year:
2023
Region / City:
Not specified
Topic:
Immunology, Cytotoxicity, Flow Cytometry
Document Type:
Research Supplementary Figures
Author:
Not specified
Target Audience:
Researchers, Immunologists
Period of Validity:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2023
Region / City:
Birmingham, UK
Field:
Medical Research
Document Type:
Research Study Participant Information Sheet
Institution:
University of Birmingham
Author:
Tom Nightingale, PhD
Target Audience:
Individuals with spinal cord injury (SCI), medical professionals, researchers
Study Duration:
3 weeks (AIM 1) and 9 weeks + 6-week follow-up (AIM 2)
Date of Approval:
2023
Date of Last Revision:
N/A
Study Phases:
AIM 1 (3 weeks), AIM 2 (9 weeks), Follow-up (6 weeks)
Study Contact:
Dan Hodgkiss, MSci
Sponsor:
University of Birmingham
Funder:
The International Spinal Research Trust (ISRT)
Journal:
World Journal of Anesthesiology
Manuscript Number:
20975
Manuscript Type:
Review
Title:
Transcranial magnetic stimulation as a new tool to control pain perception
Running Title:
Transcranial magnetic stimulation for chronic pain
Authors:
Emanuela Onesti; Maria Cristina Gori; Vittorio Frasca; Maurizio Inghilleri
Affiliation:
Department of Neurology and Psychiatry, University of Rome “Sapienza”, Rome, Italy
Corresponding Author:
Maurizio Inghilleri
Received:
June 27, 2015
Peer-Review Started:
June 30, 2015
First Decision:
September 17, 2015
Revised:
November 26, 2015
Accepted:
December 13, 2015
Publication Year:
2015
License:
Creative Commons Attribution Non Commercial (CC BY-NC 4.0)
Keywords:
Transcranial magnetic stimulation; Repetitive transcranial magnetic stimulation; Neuropathic pain; Non-neuropathic pain; Chronic pain; Neuromodulation
Study Period Covered:
1991–May 2015
Study Type:
Narrative review of controlled studies
Year:
2023
Region / city:
Cambridge, Milan, Catanzaro, Rome, Rochester
Topic:
Neuroticism, neuroimaging, vestibular disorders, fMRI, persistent postural-perceptual dizziness (PPPD)
Document Type:
Research Article
Institution:
University of Cambridge, National Research Council, Mayo Clinic, Saint Camillus International University of Health Sciences
Authors:
Luca Passamonti, Roberta Riccelli, Francesco Lacquaniti, Jeffrey P Staab, Iole Indovina
Target Audience:
Researchers, medical professionals, clinicians, neuroscientists
Period of Activity:
Ongoing
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2026
Region / City:
International
Topic:
Neuroscience, Brain Stimulation
Document Type:
Survey Questionnaire
Institution / Organization:
Research Institutions and Ethics Committees
Author:
Not specified
Target Audience:
Researchers, Ethics Committee Members
Methods Covered:
TMS, tES, tDCS
Ethical Considerations:
Approval procedures, participant consent, self-administration policies
Number of Questions:
30+
Application Scope:
Research and ethical evaluation of non-invasive brain stimulation techniques
Data Collection:
Demographics, experience, attitudes, ethical and legal perspectives
Year:
2021
Region / City:
Rome, Italy
Field:
Cancer Research
Document Type:
Article
Organization / Institution:
Sapienza University of Rome, University of Milan, Consiglio Nazionale delle Ricerche (CNR), University of Trento, University of Ferrara
Authors:
Guerriero, Claudia; Manfredelli, Marianna; Matera, Carlo; Iuzzolino, Angela; Conti, Luciano; Dallanoce, Clelia; De Amici, Marco; Trisciuoglio, Daniela; Tata, Ada Maria
Target Audience:
Researchers in Cancer Biology
Period of Validity:
N/A
Approval Date:
N/A
Modification Date:
N/A
Keywords:
glioblastoma; cancer stem cells; M2 muscarinic receptor; orthosteric and dualsteric muscarinic agonism; autophagy; apoptosis; mTORC1
Funding:
Ateneo Sapienza Funds
References:
Aoki H, 2008, Autophagy, V4, P467, DOI 10.4161/auto.5668
Context:
Scientific article exploring the role of M2 muscarinic receptor stimulation in inducing autophagy and apoptosis in glioblastoma cancer stem cells, and the differential effects of orthosteric and dualsteric agonists.
Year:
2022
Region / City:
United States
Topic:
Medical necessity, prior authorization, spinal cord stimulation
Document Type:
Template letter
Organization / Institution:
Abbott
Author:
Not specified
Target Audience:
Healthcare providers, insurance companies
Period of validity:
Not specified
Approval date:
Not specified
Amendment date:
Not specified
Note:
Year
Subject:
Anatomy
Document Type:
Educational Worksheet
Target Audience:
Students
Context:
Educational worksheet on nervous tissue and spinal cord anatomy, including exercises on neuron types, reflex arcs, and spinal meninges.
Year:
2013
Region / City:
Manchester, NH
Subject:
Neurological Rehabilitation, Spinal Cord Injury
Document Type:
Course Outline, Educational Materials
Organization / Institution:
Franklin Pierce University, Doctor of Physical Therapy Department
Authors:
Lisa Doyle, PT, MS, DPT; Jennifer Parent-Nichols, DPT, PCS
Target Audience:
Doctor of Physical Therapy students, Clinical Educators
Period of Action:
Winter term, second year
Approval Date:
Not specified
Revision Date:
Not specified
Year:
2018
Region / City:
Milton Keynes
Theme:
Healthcare policy for spinal cord injury (SCI) care
Document type:
Policy
Organization:
Spinal Injuries Association
Author:
Carol Adcock, Debbie Green
Target audience:
Healthcare providers, clinical staff, NHS trusts
Review date:
January 2023
Approval date:
July 2018
Revision date:
January 2025