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January 1, 2006
 
MEDICAID INFORMATION RELEASE MA05-41
 
TO:                 Physicians, Osteopaths, Anesthesiologists, Mid-level Practitioners, Hospitals, and Ambulatory Surgical Centers
 
FROM:          Leslie M. Clement, Deputy Administrator
 
SUBJECT:     CHANGES IN PRIOR AUTHORIZATION REQUIREMENTS FOR SPINAL NEUROSTIMULATORS
 
Effective for dates of service on or after 02/01/2006, prior authorization will be required for implantation of spinal neurostimulators. This includes all services, supplies, facility, and ancillary charges related to implantation of spinal neurostimulators with the following codes:
 
·        ICD-9 Procedures and Interventions code 03.93, (Implantation or replacement of spinal neurostimulator lead(s), including all services related to inpatient, outpatient, and ambulatory surgical center charges for services.
·        CPT procedure codes 63650, 63655, 63660, 63685, and 63688
 
To request prior authorization for implanted spinal neurostimulators:
 
 
 
  • Include the following documentation when submitting a request for prior authorization:
ð      other, less invasive procedures that are contraindicated, or have been attempted without success;
ð      client has received a multidisciplinary team screening and evaluation;
ð      client has received a psychological evaluation; and
ð      when requesting prior authorization for permanent implanted spinal neurostimulators, document that relief of pain has been demonstrated with a temporary implanted electrode(s).
 
PROVIDER HANDBOOK:
This information release changes information in the following section(s) of the Idaho Medicaid Provider Handbook: 
Physician/osteopath handbook, Section 3.3.3.6, which is available online at: http://www.healthandwelfare.idaho.gov/_Rainbow/Documents/medical/s3_004_005_physician.pdf
Hospital handbook, Section 3.4.13 through 3.4.15, which is available online at:
 
If you have questions concerning this Information Release, please contact Arla Farmer, Bureau of Medical Care, at (208) 364-1958 or by FAX at (208) 332-7285.
 
Thank you for your continuing participation in the Medicaid Program.
 
LC/af