Anthem Blue Cross Blue Shield / Elevance (Commercial) · dorsal root ganglion stimulation

.DRGANTHEM

Assessment: *** — CRPS type I/II of the lower extremity (*** limb/side), moderate-to-severe
chronic intractable pain meeting the Budapest criteria, with a failed trial of regional
sympathetic blocks. Pain is >=3/10 and the patient is unable to perform >=2 ADLs/IADLs;
documented pathology is on file. I have selected DRG stimulation as an alternative to
dorsal-column SCS; there is no functioning or failed SCS in place, and simultaneous SCS and
DRG placement is not planned.

Medical necessity per Carelon MSK01-0626.1 (Interventional Pain Management, to which
Anthem/Elevance delegates this authorization): the patient has completed >=6 consecutive
months of physician-supervised multimodal conservative management — physical therapy or a
supervised home program, pharmacologic therapy, interventional blocks as appropriate, and
complementary measures — without significant improvement, or these were contraindicated:
*** . Psychological evaluation by a licensed mental-health provider was completed within
the 6 months preceding this trial request and clearance was obtained, with no evidence of
untreated drug addiction.

Plan: Percutaneous DRG stimulation trial. Permanent implantation requires a trial of >=3
days with >=50% reduction in pain or analgesic use together with documented functional
improvement. Risks, benefits, and alternatives discussed; consent obtained.