OasisLMS

Navigating the complexities of prior authorization is one of the most persistent challenges clinicians face when securing access to care for their patients. This Prior Authorization Module includes two presentations.

The first presentation, Medicare and Prior Authorization, outlines the structure of Medicare coverage and the evolving requirements for prior authorization (PA), particularly for neuromodulation therapies like spinal cord stimulation (SCS). It explains the roles of Medicare Administrative Contractors (MACs), National Coverage Determinations, Local Coverage Determinations (LCDs), and the hierarchy of coverage, while emphasizing documentation and clinical criteria needed for approval 1. 

The second presentation, Commercial Payers and Prior Authorization, focuses on commercial payer policies and the appeals process. It details how coverage decisions are made, the influence of third-party management companies (e.g., Evi Core, Carelon), and the steps physicians and patients must take to appeal denials. It also highlights the importance of individualized documentation and understanding payer-specific criteria 2. 

Together, these presentations equip clinicians with the knowledge to navigate complex payer systems, secure treatment approvals, and advocate effectively for their patients.

Administrators, Advanced Practice Providers, Executives, Neurosurgeons, Neurologists, Nurses, Nurse Practitioners, Physicians, Physician’s Assistants, Pain Medicine Physicians, and Physical Medicine and Rehab Physicians

Following participation in this activity learners will be able to:

• Describe the structure and function of Medicare coverage, including the roles of National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Advantage plans. 
• List the documentation and clinical criteria required to obtain prior authorization for neuromodulation therapies from both Medicare and commercial payers. 
• Compare the prior authorization requirements and coverage policies of Medicare with those of commercial insurers and third-party management companies. 
• Demonstrate how to prepare a comprehensive medical necessity letter and supporting documentation for prior authorization and appeals. 
• Explain the steps involved in the patient appeals process following a denial, including rights under the Affordable Care Act and strategies for successful reconsideration.

	David Provenzano, MD  President, Pain Diagnostics and Interventional Care  Sewickley, PA
	Joshua Rosenow, MD  Director, Functional Neurosurgery, Northwestern University Feinberg School of Medicine  Chicago, IL

None of the planners, staff, reviewers, or faculty have any relevant financial relationships to disclose with ACCME ineligible companies except those listed below. All relevant financial relationships have been mitigated.

David Provenzano, MD | Speaker
Avanos: Consulting Fees (Ongoing) | Avanos: Contracted Research (Ongoing) | Boston Scientific: Consulting Fees (Ongoing) Boston Scientific: Contracted Research (Ongoing)| BRIXTON: Consulting Fees (Ongoing) | BRIXTON: Contracted Research (Ongoing) | Medtronic: Consulting Fees (Ongoing)| Medtronic: Contracted Research (Ongoing) | SI-BONE: Consulting Fees (Ongoing) | WAVEGATE: Consulting Fees (Ongoing)

Joshua Rosenow, MD | Speaker
AIM Medical Robotics: Consulting Fees (Ongoing | Boston Scientific: Consulting Fees (Ongoing) | Boston Scientific: ISR Research Grant (Ongoing) | Monteris: Consulting Fees (Ongoing)| Stryker: Consulting Fees (Ongoing)

Educational Programs (except the in-person Annual Meeting) – Fees for programs are non-refundable. For more information, please visit the NANS website for the full refund policy.

The North American Neuromodulation Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation
The North American Neuromodulation Society designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CREDIT FOR NURSES AND NURSE PRACTITIONERS 

American Nurses Credentialing Center 

The American Nurses Credentialing Center (ANCC) accepts attendance at educational activities approved for AMA PRA Category 1 Credit ™ for recertification. To renew an ANCC certification, at least 60 of the 75 contact hours must be formally approved for continuing education hours.  

This activity meets the criteria for acceptable Continuing Education Hours. 

As needed, you can use these formulas to convert continuing education credit or academic hours:  

1 Contact Hour	=	60 Minutes or 1 AMA PRA Category 1 Credit ™
60 Minutes	=	1 Contact Hour or 1 AMA PRA Category 1 Credit ™

Acceptable supporting documentation 
Use your "My Account" to complete the CH section of the Professional Development Record to document the courses attended and the hours obtained. If the course title(s) does not reflect the content, you must provide a brief description of the content. Certificates of completion in lieu of completing the Professional Development entries will not be accepted. Keep documentation of all completed activities for 7 years in case you are audited by the ANCC.  

Credit for Physician Assistants 

The American Academy of Physicians Assistants (AAPA) 

The American Academy of Physicians Assistants (AAPA) accepts attendance at educational activities from organizations accredited by the Accreditation Council on Continuing Medical Education (ACCME).  

This activity meets the criteria for acceptable AAPA Category 1 CME. 
As needed, you can use the formula below to convert continuing education credit or academic hours:

1 AMA PRA Category 1 Credit ™ credit hour

=

1 AAPA Category 1 CME Credit

Education credits can be submitted by logging into the online submission system,  PA Portfolio. You can transfer AAPA-earned Category 1 CME credits from PA Portfolio to The National Commission on Certification of Physician Assistant (NCCPA). In the CME section, simply click the send button next to the items you would like to transfer. 

Be sure to have the following information available when entering the education: 

• Title of the program 
• Provider – the organization that is administering the program 
• Number of credits 
• Sponsor – the organization that designates the program for CME credit 

For more information regarding recertification requirements, please contact the AAPA directly: 
American Academy of Physician Associates Phone: 703-836-2272 (option 1) M-F from 9-5 ET or Email: cme@aapa.org 

The National Commission on Certification of Physician Assistant (NCCPA) 
The National Commission on Certification of Physician Assistant (NCCPA) accepts Category 1 CME credit for activities designated by the AMA PRA Category 1 Credit ™ from organizations accredited by the Accreditation Council on Continuing Medical Education (ACCME) 

This activity meets the criteria for acceptable AAPA Category 1 CME. 

As needed, you can use the formula below to convert continuing education credit or academic hours:  

1 AMA PRA Category 1 Credit ™ credit hour

=

1 Category 1 CME Credit

Acceptable supporting documentation 

Acceptable supporting documentation for Category 1 credits includes the certificate. The documentation should indicate the PA's name, the accredited ACCME organization's name, the CME activity's title and date, and the number of credits designated for Category 1 Credit.  

NCCPA provides the option to upload CME certificates when logging in, but you are not required to submit documentation at the time that you log credits. However, be sure to keep documentation of all completed Category 1 CME activities for 7 years in case you are audited by NCCPA.  

Check with your state licensing board regarding their individual auditing and documentation requirements. 

For more information regarding recertification requirements, please contact the NCCPA directly: National Commission on Certification of Physician Assistants (NCCPA)   

Phone: 678.417.8100 Email: nccpa@nccpa.net

An evaluation for this educational activity is required to claim credit and attendance hours. The evaluation must be completed when you finish the activity.