Implanted Spinal Neurostimulators

Indicate of request is trial or permanent placement;
Physician notes include:
- Condition requiring procedure
- Physical examination
- Treatments tried and failed but not limited to:
  - Spine surgery
  - Physician therapy
  - Medications
  - Injections
  - Psychological therapy
Documentation of appropriate psychological evaluation Medicare Mental Health (MLN Booklet MLN1986542)
For permanent placement, include documentation from above and documentation of pain relief with temporary electrode(s)
- Successful trial associated with at least 50% reduction of target pain or 50% reduction of analgesic medications
Services associated with devices under IDE study must undergo prior authorization and meet coverage requirements in NCD 160.7

Code	Description
63650	Implantation of spinal neurostimulator electrodes accessed through the skin

The Prior Authorization for Certain Hospital Outpatient Department Part B Associated Codes List is in Appendix B of the CMS OPD Operational Guide.

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Implanted Spinal Neurostimulators - JF Part B