SCS Traditional denied for failing step therapy by eviCore healthcare?

NACC-aligned. Conservative therapy >=6 weeks, BHE clearance, >=50% trial relief documented for SCS implant.

Submit eviCore PA retroactively with full clinical. Psychologist letter explicitly stating 'appropriate candidate per NACC criteria.' Trial diary: daily NRS, ODI pre/post, analgesic reduction, patient global impression.

## Why eviCore Requires Step Therapy Before Traditional SCS

Spinal cord stimulation is a procedural intervention, and eviCore's clinical coverage guidelines for SCS uniformly require documented failure of a defined sequence of conservative and interventional pain treatments before an SCS implant will be approved. A step-therapy denial means eviCore determined — correctly or incorrectly — that the submitted record does not demonstrate completion of the required prior-treatment sequence.

## Why This Denial Is Often Overturned

Step-therapy denials for SCS are among the most frequently reversed on appeal because the required prior treatments are often already in the patient's chart — they simply were not organized and submitted in a way that matched eviCore's criteria checklist. If your physician documented treatments that satisfy the step requirements, a well-organized appeal with a criteria map will directly refute the denial. If you have a comorbidity or clinical reason why a specific step was contraindicated, your physician can document that clinical judgment.

## Your Federal Appeal Rights

• Internal appeal: File a written internal appeal under your plan's ERISA §503 or state-law procedures. Request the specific clinical rationale and the exact guideline version used to deny.
• External review (ACA §2719): This denial involves a medical-necessity/clinical-criteria determination and is eligible for binding independent external review. The window to request external review is typically up to four months from denial — verify on your Explanation of Benefits.
• Expedited review: Available if your clinical situation is time-sensitive.

## Documentation to Gather

1. Complete treatment history — a chronological list of every prior treatment (medications, physical therapy, injections, psychological evaluation, etc.) with start dates, end dates, doses where available in the chart, and documented outcomes or reason for discontinuation. 2. Diagnosis confirmation — the underlying pain diagnosis, supported by imaging, nerve-conduction studies, or specialist evaluation as applicable. 3. Clinical severity over time — chart notes showing functional decline or inadequate pain control despite prior treatments. 4. Prescriber letter — an explicit letter from the referring or implanting physician stating which steps have been completed, when, and the clinical outcome of each, mapped to eviCore's published SCS coverage criteria. 5. eviCore guideline copy — request the exact guideline version used in the denial; compare its step requirements to your treatment record line by line.

## Criteria-Mapping Approach

Obtain eviCore's published clinical coverage criteria for SCS (available on eviCore's provider portal or by written request). Create a two-column table: left column lists each step-therapy requirement; right column cites the chart entry — treatment name, date, duration, outcome — that satisfies it. If any step was skipped for a documented clinical reason, include the physician's note explaining why. Submit this structured map as the centerpiece of your appeal brief.