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SCS pain coverage issues



  • Now you can say you know someone who paid for their eval. I used the Doctor who my PM recommended and he was out of network and I had yet to meet my out of network deductible. The eval was $150.00.

  • Is your insurance refusing to pay because you don't have mental health coverage under your current policy?

    I had that problem with my psych eval and apparently it was fairly common at the office of the doctor I was seeing at that time, because their office personnel weren't as educated on the issue as they should be. They told me my insurance denied the coverage, so I'd have to pay it out of pocket.

    I contacted my insurance company, who one would expect would be quite agreeable to not paying for something, and they told me the office filed the claim under the wrong CPT code.

    If that's the issue you're having, ask them what CPT code they're using. My (former) doctor's office was trying to bill it under 90801, which is a diagnostic pyschiatric interview, so the insurance company kicked it back.

    If they bill it as 96150, it falls under the Health and Behavior Assessment/Intervention Codes instead of the psychiatric codes.
    CPT Codes 96150–96151
    96150 Health and behavioral assessment (e.g., health-focused clinical interview, behavioral observations, psychophysical monitoring, health-oriented questionnaires), each 15 minute face-to-face with the patient; initial assessment

    96151 Health and behavioral assessment (e.g., health-focused clinical interview, behavioral observations, psychophysical monitoring, health-oriented questionnaires), each 15 minute face-to-face with the patient; re-assessment
    DESCRIPTION DETAILS4: HBI codes report assessment of psychological, behavioral, emotional, cognitive, and relevant social factors that can help to prevent, treat, or manage physical health problems. The assessment must be associated with an acute or chronic illness, the prevention of a physical illness or disability, and the maintenance of health. The initial assessment (96150) and re-assessment (96151) apply to each 15-minute direct, face-to-face session with the patient. A reassessment (96151) is reported to obtain objective measures of goals formulated in the initial assessment and to modify plans as is indicated to support the goals.

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  • The Pychological Evaluation is a a requirement of the insurance company. The cost of my evaluation was $600 and Blue Cross paid the entire amount.
  • I hope others continue to stumble on this thread, much as I did! I had the trial which was about 70% successful in covering my LOW BACK pain. I went ahead with the implant, and now I am lucky if I achieve 20-30% coverage of my back pain, however something is better than nothing. I have found a lot of your success comes from the relationship I have built with my Medtronic rep, who works tirelessly on my behalf to find the "miracle" programs that work best for level of activity, pain and needs. I have been "reprogrammed" more than what the average was given to me prior to my surgery, and although every reprogramming hasn't been the greatest results, we (my rep, doctor and myself) ALWAYS gain a wealth of information about my device and needs.
    After undergoing the surgery, personally, I cannot fathom giving up on the device and its elements. Often I feel trial and error is the best approach! Keep trying, keep tweaking the settings and programming options! The technology is there to help those that are willing to try, and understand it's not an EASY process. Its hard work and ultimately a lifelong commitment.
    I say all of the above with limited results, but I am satisfied with the limited results I have received thus far. I am almost 3 years post op, and currently 6 1/2 months pregnant, and putting the limits of my SCS to the max!
    This, as my disclaimer states, is based on my own personal experience.
    Cheers to all that follow in this path, and good luck to all fellow suffering souls out there.
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