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Obtaining Coverage for Pain Therapies

Neurostimulator and Intrathecal Drug Delivery

Introduction
Medtronic Pain Therapies are a class of pain management therapies, which include neurostimulation and intrathecal drug delivery.

Neurostimulation is a pain treatment that delivers electrical stimulation to the spinal cord or peripheral nerve to inhibit or block the sensation of pain. Intrathecal drug delivery administers pain medication directly to the pain pathways within the spinal cord. Both therapies are appropriate for carefully selected patients who have experienced inadequate pain relief or intolerable side effects from more conservative pain treatment options. Many health plans and insurance companies, referred to as payors, cover most of the cost of pain therapy. It is highly recommended that your doctor contact your payor to get approval before it can be implanted. This process is called prior authorization.

• Frequently Asked Questions on Insurance Coverage
• Prior Authorization Request
• Coverage Denials
• Your Right to Appeal
• Keys to a Successful Appeal
• Other Resources

Frequently Asked Questions

Q. Will my insurance company pay for intrathecal drug delivery and/or the neurostimulator system?
A. Yes. Both systems are approved by many insurance carriers. As with many therapies, your doctor will have to get approval from your insurance company before you can receive the system. Consult your doctor or insurance carrier for more specific information.

Q. Does Medicare covers the neurostimulator and/or intrathecal drug delivery system?
A. Yes. The systems are approved for coverage by Medicare. Medicare will pay 80% of the cost for the Medtronic Pain systems as long as the procedure(s) is "medically necessary". Consult with your doctor on the Medicare Conditions of Coverage for both the neurostimulator and/or intrathecal drug delivery.

Q. Do Workers' Compensation carriers cover the neurostimulator and/or intrathecal drug delivery system?
A. Yes. Most Workers' Compensation carriers cover for both systems. As with many therapies, your doctor will have to get approval from your Worker's Compensation carriers before you can receive treatment. Consult your doctor or Worker's Compensation for more specific information.

Q. What is a CPT code?
A. CPT code is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. CPT is the acronym for Current Procedural Terminology.

Q. What are the CPT codes for neurostimulation?
A. Neurostimulation Therapy - Commonly Billed Codes

Q. What are the CPT codes for intrathecal drug delivery?
A. Intrathecal Drug Delivery for Non-Cancer and/or Cancer Pain - Commonly Billed Codes

Q. What is a HCPCS code?
A. HCPCS is a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. HCPCS (pronounced "hick-picks") is the acronym for Healthcare Common Procedure Coding System.

Q. What are the HCPCS for neurostimulation?
A. Neurostimulation Therapy for Chronic Pain - Commonly Billed Codes

Q. What are the HCPCS for intrathecal drug delivery?
A. Intrathecal Drug Delivery for Non Cancer and Cancer Pain - Commonly Billed Codes

More Frequently Asked Questions

Prior Authorization Request

Typically, your practice makes the initial prior authorization request to your payor for a neurostimulation or intrathecal drug delivery system implant.

• He or she drafts a Letter of Medical Necessity describing the medical need and why they believe the neurostimulation or intrathecal drug delivery therapy can benefit the patient.
• The payor reviews the letter and decides if they will or will not reimburse for the implant procedure.
• If they decide to cover the procedure, the payor will inform the doctor's office and the procedure is scheduled

Tips

If the payor decides not to cover the procedure, you have the right to appeal that decision. In the initial authorization process, the role of the patient or family member is minimal. However, there are steps that can be taken to help the appeal process.

• Obtain the name and phone number of the staff person in the doctor's office who is assigned to coordinate and follow up with the prior authorization request made by the doctor on your behalf.
• Have a discussion with that person regarding the process and time expected to secure the prior authorization.
• Consider following up with that individual once every one or two weeks regarding the status of your prior authorization request.

If you would like assistance, Medtronic can submit prior authorization requests on your behalf. Please contact our Prior Authorization and Coding Hotline at 1-800-292-2903.

Coverage Denials

The prior authorization request may be denied because the payor does not have enough information needed to make a favorable coverage decision. Their letter of denial may give one of the following reasons why the payer will not cover pain therapy.

• The therapy is investigational/experimental
• The therapy is not medically necessary
• The therapy is not a standard of care

If you would like a sample of appeal letters, please go to Keys to a Successful Appeal below, or call our Prior Authorization and Coding Hotline at 1-800-292-2903.

Your Right to Appeal
If your payor denies coverage for neurostimulation or intrathecal drug delivery for chronic pain, you have a right to appeal. Coverage is sometimes denied because the payors do not fully understand the therapy. Consequently, providing information to them can be helpful. Be sure to check your insurance carrier's Certificate of Coverage for instructions on the appeal process offered by your insurance plan.

Appealing a coverage decision can be a lengthy process. Do not get discouraged. There are resources available to assist a patient or family member through an appeal process. A patient or family member may contact Medtronic at 1-800-292-2903 to guide you in the prior authorization process.

Keys to a Successful Appeal
The appeal process ensures that any critical decision that affects your care (such as whether you will receive neurostimulation or intrathecal drug delivery for chronic pain) is given the consideration it deserves. While the information on this website may be helpful to you, Medtronic cannot guarantee your success in gaining coverage. There are four factors that, when used together, give you the best chance to overturn a denial:

1. Send a one or two page letter written by you to the payor requesting that the coverage decision be reversed. Your letter should be written within the deadline mentioned in the denial notice, usually 1 - 4 weeks. It should contain relevant information about you, your condition, and the therapy. (The following are sample letters for you to use. Please select the therapy and choose the reason of denial.)

2. Ask your doctor to send a second letter asking the payor to reconsider the decision to deny coverage. For faster results ask your doctor to call the payor. A second letter, written by your doctor, should contain supporting information that may not have been included in the first letter. This could include information about you, your condition, and Neurostimulation Therapy for Chronic Pain. Ask your doctor for a copy of the second letter to keep for your records.

3. Be persistent. Follow up with the doctor, medical office billing staff, and payor staff. The doctor's office staff is usually quite willing to help out (write letters, make calls, etc.) but you need to be in charge of the process.

4. Write down each contact you make with your doctor, office staff and payor in a notebook. Note the date, contact person, and nature of your discussion. This will help you keep track of the details involved with your interactions.

Other Resources:
(available after the payor's appeal processes are exhausted)

1. External Review Process: Medicare and many other payors have contracts with independent companies to resolve disputes. If you are a Medicare plus Choice beneficiary and coverage for Intrathecal Drug Delivery For Cancer, Non-Cancer Pain and Neurostimulation Implantable Therapy is denied, the denial is automatically reviewed by the Center of Health Dispute Resolution (CHDR) for a final coverage decision. You may find additional information on the Medicare appeal process at www.medicareappeal.com.

If you have commercial insurance (not Medicare), the initial denial is not automatically forwarded to a dispute resolution company. If a dispute resolution service is available, either you or your doctor can request a review. Contact your payor for more information on their external review process/service.

2. Employer Group Assistance: Employers who provide benefits to their employees through non-Medicare payors can often request that "an exception to benefits" be made that allows coverage for Intrathecal Drug Delivery For Cancer, Non-Cancer Pain and Neurostimulation Implantable Therapy. Call your employer's Human Resources Department for benefit information and contacts.

3. Insurance Commissioner: Contact the insurance commissioner in your state to discuss possible ways to pursue coverage and payment through your payor. You can find an updated list of insurance commissioners at www.naic.org

4. Attorney General: Contact your state attorney general for assistance with an appeal process. A formal health care complaint must be submitted within a certain time period. A current list of state attorney generals can be found at www.naag.org.

5. The Medtronic Economic and Reimbursement Solutions Team. Contact a Specialist at 1-800-292-2903 for guidance on state specific insurance coverage, prior authorization and/or appeal process.