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Spinal Cord Stimulation Prior Authorization Form Page 1 of 1 Please return completed form to the Utilization Management Department at (401)4596023. Please refer to Neighborhoods Clinical Medical Policy

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Consult with a healthcare provider to determine if spinal cord stimulation is the right treatment option for you.

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Undergo a psychological evaluation to assess your suitability for spinal cord stimulation.

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What is spinal cord stimulation prior?

Spinal cord stimulation prior is a process where a healthcare provider submits a request to a payer for approval before performing a spinal cord stimulation procedure on a patient.

Who is required to file spinal cord stimulation prior?

Healthcare providers who plan to perform a spinal cord stimulation procedure are required to file a prior authorization request with the payer.

How to fill out spinal cord stimulation prior?

To fill out a spinal cord stimulation prior authorization request, healthcare providers need to provide patient information, medical history, procedure details, and the reason for the request.

What is the purpose of spinal cord stimulation prior?

The purpose of spinal cord stimulation prior is to ensure that the proposed procedure is medically necessary and meets the criteria set by the payer before it is performed.

What information must be reported on spinal cord stimulation prior?

On a spinal cord stimulation prior authorization request, healthcare providers must report patient demographics, medical history, treatment plan, and any relevant clinical documentation.

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