Implanted Spinal Neurostimulators - JF Part A

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

• Local Coverage Determination: Spinal Cord Stimulators for Chronic Pain (L36204)
• Local Coverage Article (A57792)

Codes

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

Resources

• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services (CMS)
• Federal Register
• Spinal Neurostimulator Implantation