Spinal Cord Simulator Form Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#*0 of 11 max characters Member's DOB* MM slash DD slash YYYY Date of service (if known) MM slash DD slash YYYY Name* First Last Error Message Provider InformationHospital/Facility NPI* 10 digitsHospital/Facility Name (where procedure will take place)* Error Message Ordering MD* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) (Click + or - at the right to add up to 5 CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Etiology/Specific Location of Pain* Location of Proposed Treatment* Please indicate if the member has any of the following conditions (check all that apply)* Radicular extremity pain resulting from failed back surgery syndrome Damage to peripheral nerves Chronic regional pain syndrome (reflex sympathetic dystrophy) Arachnoiditis Please Check all that apply if applicable Nerve injury secondary to stroke, spinal cord injury or other central nervous system disease Chronic malignant pain including: Headaches, neuralgia, phantom limb pain, post herpetic neuralgia, intractable angina, diabetic neruopathy Cervical spine trauma, disc herniation, or failed cervica spine syndrome Please indicate if surgical intervention is an option for the patient*Please indicate if surgical intervention is an option for the patient *YesNoIf No, please indicate reason*Has the patient undergone a psychological or psychiatric evaluation*Has the patient undergone a psychological or psychiatric evaluation *YesNo Please submit clinical notes with documentation of previous treatments and outcomes, which may include medications, surgery, physical therapy, and/or psychological treatment. Please submit documentation of trial of spinal cord stimulation with an external pulse generator for 3-7 days, and the results. Attach Clinical information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Reset to re-sign.Signature Date* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Reset to re-sign.Signature Date* Comments Authorization is not a guarantee of payment CAPTCHA