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An implanted device that sends low levels of electricity directly into the spinal cord to relieve pain. Spinal cord stimulators require two procedures:
- The Trial AND
- The Permanent Implantation
Additional Information:
- Spinal cord stimulators should be reserved as a last resort for pain management.
- These requests should almost always be done in an outpatient setting:
- Exception: If there is an additional request associated with the stimulator request that meets inpatient criteria.
- Dorsal Root Ganglion Stimulation (DRG) requests do not meet Humana Medicare criteria and will pend or be denied.
Terms to know:
- Pulse generator: small, pacemaker-like battery pack. Also called batteries, generators, IPG (internal pulse generator)
- Lead: placed above the spinal cord
- Extension wire: connects the lead to the generator
Procedure Types:
|
Trial 1st phase |
Under sedation, the patient received a lead/ electrode inserted to the vertebral level desired. If 50% or greater pain relief and improved functionality is achieved, it is considered a successful trial and moves onto the permanent implantation phase. |
|
Permanent Implantation 2nd phase |
Patient is kept awake during this procedure to ensure proper placement of a longer term stimulator. |
| Revision | A provider may need to perform a revision for: inadequate coverage of their pain, or a need to revise the area of implantation. |
| Replacement | May occur for replacement of the battery of the stimulator. |
| Removal | May occur for things such as: the patient presenting with signs and symptoms of infection at implantation site, or if the patient needs to have an MRI performed. |
Depending on the procedure codes entered for authorizations, the following documentation may be required. In very few circumstances, additional information that is not listed may be requested.
For every authorization, regardless of service, please include an office visit note with TWO (2) patient identifiers.
We encourage all users to submit the following documentation with their requests for Commercial and Medicare members:
| Documentation | Details |
| Advanced imaging |
|
| Temporary Implanted Electrode (trial) | Documentation of at least 50% reduction in pain and improved function |
| Patient information | Most recent office visit note(s) |
| Outcome of prior treatments |
List all treatments including: outcome, duration and dates of treatment. Must have occured within the last 12 months for commercial (does not apply to Medicare)
|
| Physical Therapy | Including home exercise program w/ duration and dates of PT |
| Steroid injections | If medically appropriate and not contraindicated (include dates) |
| Medications |
If medically appropriate and not contraindicated for all medications/injections, include dates: Nonsteroidal anti-inflammatory drugs [NSAIDs], Non-narcotic analgesics, injected medications, Narcotic analgesics |
| Chronic Intractable Pain | Note intractable pain and functional impairment of activity of daily living (ADLs) |
- Always answer the clinical assessment questions thoroughly.
- You will not need to indicate laterality for these requests.
- For each lead intended for the procedure, there should be an individual procedure code, "63650" entered in the Cohere Portal.
