Prior Authorization for Spinal Neurostimulator Implantations: The Centers for Medicare & Medicaid Services (CMS) implemented a prior authorization requirement for spinal neurostimulator implantations surgeries on July 1, 2021. This policy change took effect after the Office of Inspector General (OIG) had concluded its field work but before the release of its investigation report.
CMS specifically targeted CPT codes 63650, 63685, and 63688 for this requirement. These codes correspond to the implantation, replacement, and revision of spinal neurostimulator devices. By focusing on these codes, CMS aimed to simplify the initial implementation of the prior authorization process.
To navigate this new requirement, patients and healthcare providers must understand the necessary treatment journey and medical documentation. The following information outlines the steps involved in obtaining prior authorization for a spinal neurostimulator.
Spinal Neurostimulation: A Pain Management Breakthrough:
Spinal neurostimulation is a medical procedure used to manage severe chronic pain when other treatments have been ineffective. It works by blocking pain signals from the affected area before they reach the brain. This is achieved by implanting electrodes (leads) into the epidural space, which is located outside the spinal cord. A small generator is then placed under the skin and connected to the leads.
There are various types of generators, some of which operate continuously while others can be controlled remotely. The healthcare provider programs the generator during the procedure to ensure it’s functioning correctly. Adjustments can be made as needed in follow-up appointments. This treatment is often considered a better option than long-term opioid medication, which can lead to addiction.
To obtain prior authorization for a spinal neurostimulator procedure under Medicare:
To obtain prior authorization for a spinal neurostimulator procedure under Medicare, providers must submit a complete prior authorization request that includes the patient’s medical records to demonstrate medical necessity.
Refer to Section 6.3.2.2 of the Prior Authorization (PA) Program for Certain Hospital Outpatient Department Services Operational Guide for detailed requirements.
Key points to remember:
- Providers performing both trial and permanent implant procedures need submit only one prior authorization request.
- If the trial procedure occurs outside the hospital outpatient department, a separate prior authorization request is required for the permanent implantation.
- Thorough documentation of medical necessity is essential for successful prior authorization
Understanding Medicare Coverage for Spinal Neurostimulators
To qualify for Medicare coverage of a spinal neurostimulator, a patient must first be diagnosed with a chronic condition causing intractable pain. This means the pain is severe, persistent, and cannot be adequately managed with other treatments.
Medicare’s National Coverage Determination (NCD) outlines the criteria for coverage. It includes peripheral nerve stimulators, deep brain neurostimulators, and spinal neurostimulators.
Your role as a healthcare provider is crucial in documenting the patient’s condition to justify the need for spinal neurostimulation. This documentation should detail:
- The specific location of the pain
- Any underlying conditions contributing to the pain
- The duration of the pain
- Previous treatment attempts and their effectiveness
Local coverage determinations (LCDs) and local coverage articles (LCAs) may also apply in your area, providing more specific guidelines and ICD-10-CM codes.
Common diagnoses associated with spinal neurostimulator procedures include:
- Complex regional pain syndrome
- Chronic back pain
- Post-laminectomy syndrome
- Diabetes-related neuropathy
- Other neuropathic pain
Importance of Physical Examination Documentation
A thorough physical examination is essential for supporting the diagnosis of a condition that necessitates a spinal neurostimulator. Clear and detailed documentation of this exam is crucial to establish medical necessity. Vague findings or generic statements may not adequately justify the need for the device.
Medicare’s National Coverage Determination (NCD) requires a “careful screening, evaluation, and diagnosis by a multidisciplinary team” before implantation. While the NCD doesn’t explicitly define a multidisciplinary team, it typically includes:
- Pain management specialists
- Neurosurgeons
- Psychiatrists or psychologists
- Anesthesiologists
- Neurologists
In addition to the psychological evaluation, a comprehensive physical examination is a key component of this multidisciplinary assessment.
Importance of Pre-Surgical Psychological Evaluation
The Office of Inspector General (OIG) has highlighted the frequent absence of psychological evaluations before spinal neurostimulator surgeries for chronic pain. These evaluations are vital for understanding how psychological factors might influence the patient’s pain experience and treatment outcomes.
Psychological factors can include dysfunctional behaviors or social issues that may exacerbate chronic pain. Addressing these issues before surgery can improve the chances of successful treatment.
A psychological evaluation typically assesses:
- Sensory, affective, cognitive, and behavioral aspects of pain
- Expectations of benefits from the implanted device
- Personality and psychosocial factors influencing treatment outcomes
Medicare’s coverage criteria for mental health services are outlined in MLN article MM1986542, including eligible providers and covered services.
Meeting NCD Coverage Requirements:
To meet NCD coverage requirements, the implanted neurostimulator procedure must be the last resort for managing chronic pain. This means that other treatment options have been exhausted or are deemed inappropriate.
Potential treatments may include:
- Conservative therapies: Physical therapy, chiropractic care
- More invasive options: Spinal surgery, injections
The choice of treatment depends on the underlying cause of the pain, which can often be determined through medical history, physical exams, and diagnostic imaging. If these methods are inconclusive, paravertebral and epidural spinal injections may be used to pinpoint the source of pain and potentially provide relief.
Examples of tried and failed treatments can include (but are not limited to):
- Spine surgery
- Physical therapy
- Medications
- Injections
- Psychological therapy
A Successful Trial Demonstrates Significant Benefits:
A successful trial of a neurostimulator electrode demonstrates significant pain relief or reduced medication needs. This is measured by at least a 50% decrease in either pain or analgesic use, and improved daily activities. For the trial, the electrodes are temporarily placed in the epidural space and connected to an external device. This differs from permanent implantation, where the generator is placed under the skin. The trial typically lasts a week and can be easily removed. Providers should carefully document any pain relief achieved during the trial. This is especially important, as the OIG report highlighted the lack of such documentation.
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