Anthem Blue Cross Blue Shield / Elevance (Commercial) · spinal cord stimulation

.SCSTRIALANTHEM

Assessment: *** — covered indication (select one): FBSS / post-surgical nerve-root injury
(chronic intractable neuropathic trunk or limb pain after spine surgery) | lumbosacral
arachnoiditis (high CSF protein and/or MRI/myelography) | CRPS I/II (Budapest criteria with
a failed trial of regional sympathetic blocks) | painful diabetic neuropathy, which
additionally requires >=12 months duration, lower-limb VAS >=5 with upper-limb VAS <=3,
EMG/NCS showing moderate-to-severe neuropathy, PDN confirmed by >=1 other specialist,
HbA1c <=10, BMI <=35, <=120 MEq/day, other causes of neuropathy excluded, optimized medical
management with failure of or intolerance to >=2 drug categories, and documented medical
clearance. Pain is >=3/10 and the patient is unable to perform >=2 ADLs/IADLs; documented
pathology is on file.

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. At least one surgical opinion — *** — documents no surgically
correctable lesion (not applicable to CRPS or painful diabetic neuropathy).

Plan: Percutaneous SCS 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.