Prior Authorization Module: How to Win the Game and Help Your Patients-Presentation 1

Video Transcription

Video Summary

Dr. David Provenzano, co-chair of the Advocacy and Policy Committee for the North American Neuromodulation Society, provides an overview of Medicare coverage and prior authorization processes for neuromodulation therapies. He explains Medicare’s structure, including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and the growing role of Medicare Advantage plans, which now cover over 50% of Medicare beneficiaries. He highlights the importance of understanding Medicare Administrative Contractors (MACs), who manage claims and coverage guidelines regionally. Provenzano discusses requirements for prior authorizations, particularly for spinal cord stimulation (SCS) and facet joint procedures, noting recent expansions of these requirements in hospital outpatient departments. He stresses the need for thorough documentation of conservative treatments, psychological evaluations, and surgical candidacy. The talk emphasizes the complexity of navigating coverage policies and the importance of provider advocacy to facilitate patient access to evidence-based neuromodulation therapies while minimizing administrative burdens.

Keywords

Medicare coverage

prior authorization

neuromodulation therapies

National Coverage Determinations

Medicare Advantage plans

spinal cord stimulation