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Sacral Neuromodulation

  • Education and Training
  • Efficacy
  • Products and Procedures
  • Reimbursement and Practice Management
  • Indications, Safety, and Warnings
  • Prior Authorization

    Overview

    These resources will be helpful for prior authorization requests while working directly with payers.

    View templates and sample letters
    Find coding

    For assistance with prior authorization for sacral neuromodulation, contact the Coverage and Authorization Services team.


    Online Case Submission and Real-time Status Review

    Medtronic is pleased to provide a convenient prior authorization service for requests we process on behalf of your patients. Our newly enhanced and expanded service leads the industry with expedited prior authorization time frames and our commitment to you to:

    • Complete all intake work within 1 business day of receipt
    • Complete all benefit verifications within 2 business days of receipt
    • Follow-up with payers every 3 to 5 business days after initial submission, and until payer decision is obtained

    How to submit prior authorization requests and view status:

    • Register by calling (800) 292-2903 – Once you have completed the application process, we can begin to process authorization requests that you submit online

    Log in if you have already registered for access to the Prior Authorization site

    Templates and Sample Letters

    Download templates and sample letters to assist with prior authorization and coverage for sacral neuromodulation (InterStim® Therapy).

    Prior Authorization Request Form: Sacral Neuromodulation for Urinary and Bowel Control

    Use this form to submit a prior authorization request and start the prior authorization process.

    Prior Authorization Guidance: Bowel Control

    This document serves as a tool to help physician accounts complete, submit, and obtain their own prior authorization requests from a patient's payer. The document provides direction about what information and documents you will need to gather and submit as part of the prior authorization request. In addition, you will find information about how to appeal a denial, if necessary.

    Prior Authorization Guidance: Urinary Control

    This document serves as a tool to help physician accounts complete, submit, and obtain their own prior authorization requests from a patient's payer. The document provides direction about what information and documents you will need to gather and submit as part of the prior authorization request. In addition, you will find information about how to appeal a denial, if necessary.

    Prior Authorization Customized Service Level Options

    Use this form to choose the level of service for prior authorizations.

    Sample Appeal Letter: Sacral Neuromodulation for Bowel Control

    The appeal letter template can be used with a payer to request reconsideration of prior authorization for coverage that has been denied for sacral neuromodulation for bowel control.

    Sample Appeal Letter: Urinary Control

    This appeal letter template can be used with a payer to request reconsideration of prior authorization for coverage which has been denied for sacral neuromodulation for urinary control.

    Sample Letter of Medical Necessity: Bowel Control

    Template to use on behalf of patients when requesting prior authorization for sacral neuromodulation for bowel control.

    Sample Letter of Medical Necessity: Urinary Control

    Template to use on behalf of patients when requesting prior authorization for sacral neuromodulation for urinary control.

    Medtronic provides this information for your convenience only. It is not intended as a recommendation regarding clinical practice. It is the responsibility of the provider to determine coverage and submit appropriate codes, modifiers, and charges for the services rendered. This document provides assistance for FDA approved or cleared indications. Where reimbursement is requested for a use of a product that may be inconsistent, or not expressly specified in the FDA cleared or approved labeling (e.g., instructions for use, operator’s manual, or package insert), consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. Contact your Medicare contractor or other payer for interpretation of coverage, coding, and payment policies.

    United States