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PA-2025-001
Archive Case
Case Progress
Patient Information
Provider Information
Device/Service Details
Clinical Information
Policy Review
Quality Assurance
Letter of Medical Necessity
Review & Submit
Step 5 of 8
Please review the policy and confirm your patient meets all the requirements.
Coverage & Utilization Rules Requirements
To access the full policy from Noridian, click here.
Does your patient have chronic neuropathic pain ≥ 3 months with failure of conservative therapy?
Yes
No
Does your patient have a successful psychological screening – no active substance abuse?
Does your patient have trial PNS ≤ 4 leads/≤ 16 contacts yielding ≥ 50% pain reduction?
Does your patient have documentation requirements: pain scale pre/post, med-use reduction, functional gain?
is the device approved by the FDA? (verify device approval through FDA database)
Does your patient have ≤ 2 × CPT 64555 / 365 days?
Does your patient have any of the following non-covered indications (hard stops): diffuse polyneuropathy, fibromyalgia, PNFS, etc. (refer to LCD coverage )
Continue to quality assurance