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DIAGNOSIS & CLINICAL DOCUMENTATION
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Diabetes diagnosis documented:
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Diabetes diagnosis documented: OTHER
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Painful diabetic peripheral neuropathy (PDN) diagnosis documented in the medical record:
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Symptoms are painful (not loss of protective sensation alone):
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Symptoms are painful (not loss of protective sensation alone): OTHER
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Symptom duration:
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Pain distribution:
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Baseline pain score (0-10):
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Functional limitation caused by pain:
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Focused neurological/vascular lower-extremity examination documented, including sensory findings and relevant differential diagnosis:
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Alternative causes of neuropathic pain considered/documetned when clinically indicated (e.g., radiculopathy, entrapment, B12 deficiency, alcohol/toxin exposure, chemotherapy, renal disease):
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Relevant diagnostic testing/findings (if clinically indicated):
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PRIOR CONSERVATIVE TREATMENT/RESPONSE
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Prior therapies, duration, response, intolerance, and/or contraindication are documented in the chart:
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Gabapentin:
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Gabapentin: DETAILS
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Pregabalin:
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Pregabalin: DETAILS
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Duloxetine:
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Duloxetine: DETAILS
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TCA/other neuropathic medication:
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TCA/other neuropathic medication: DETAILS
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Topical therapy:
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Topical therapy: DETAILS
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Physical therapy/activity modification:
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Physical therapy/activity modification: DETAILS
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Glycemic/metabolic optimization:
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Glycemic/metabolic optimization: DETAILS
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Other:
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Other: DETAILS
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NS100 SAFETY/CANDIDACY SCREEN
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No active infection or clinically significant skin disease at proposed auricular electrode sites.
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No implanted cardiac device or other implanted electrical stimulator that would contraindicate treatment per device labeling/treating clinician assessment.
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No implanted cardiac device or other implanted electrical stimulator that would contraindicate treatment per device labeling/treating clinician assessment.
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Pregnancy status assessed when applicable; no contraindication identified.
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Patient can understand, comply with, and safely manage the temporary wearable device and follow-up requirements.
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Device-specific indications, contraindications, warnings, precautions, and current instructions for use reviewed before placement.
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MEDICARE/PAYER COVERAGE DETERMINATION - MUST COMPLETE BEFORE TREATMENT
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Current payer policy/LCD/NCD and applicable billing article were checked on date:
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by:
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Medicare Payor Coverage Determination- must complete Before Treatment
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For Medicare Advantage/commercial payer: Authorization #
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FINAL DISPOSITION
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NOT A CANDIDATE: REASON
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CLINICIAN ATTESTATION
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