Anthem Blue Cross Blue Shield / Elevance (Commercial) · restorative neurostimulation

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from Anthem SURG.00158 only. The quantified severity window (NRS and ODI) is a hard Anthem gate: document the exact scores, not just "severe pain."

.REACTIV8ANTHEM

Assessment: *** — an adult (>=18) with chronic low back pain of >6 months from lumbar
multifidus dysfunction, non-radicular and non-neuropathic, with other sources of pain ruled
out and pain present on at least half of the days in the prior year. Severity is quantified:
NRS *** (required window 6.0-9.0, measured over 7 days) AND ODI *** (required window 30-60).

Medical necessity per Anthem SURG.00158: medical management has failed over >=90 days,
including at least one physical-therapy attempt: *** , or was contraindicated. There has been
no prior back surgery below T8, and the patient is not a surgical candidate. Documented
pathology and conservative-care records are on file.

Plan: Implantation of the ReActiv8 restorative neurostimulation system — CPT 64555 (leads)
plus 64590 (generator). Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

• diagnosis line (adult >=18; pain on >= half of days in the prior year)
• severity line NEW (NRS 6.0-9.0 over 7 days AND ODI 30-60 — quantified)
• conservative-care line (>=90 days medical management + >=1 PT attempt)
• exclusions line (no prior back surgery below T8; not a surgical candidate)

Cautions

• Anthem precertification required (implantable device pathway). No externalized trial and no psychological evaluation apply. Anthem is the only commercial carrier covering ReActiv8 (UHC and Cigna deem it investigational). Regenerate if `anthem-commercial-reactiv8.md` `version` advances past `source_version` above.