Implanted Spinal Neurostimulators

General Documentation Requirements for implanted spinal neurostimulators and related services:

  • 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
  • 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

Coverage Criteria

Codes

Code Description
63650 Percutaneous implantation of neurostimulator electrode array, epidural

 

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

Resources

 

Last Updated Fri, 13 May 2022 13:22:36 +0000