Spinal Cord Stimulator Checklist

Yes

No

Indicate if this request is for a trial or permanent placement

Documentation supports a specific condition indicated for neurostimulator placement

The implantation of the stimulator is used only as a late resort

Documentation that the specific risks and benefits of the procedure were discussed with the beneficiary

Documentation that alternatives and non-surgical options were discussed with the beneficiary

Clear documentation that the beneficiary desires surgical correction

Physician order for the procedure/device

Documentation supports that conservative treatments have been tried and failed

Pharmacological therapies

Surgical therapies

Physical therapies

Psychological therapies

Evaluation performed by a qualified professional

Psychiatrist

Psychologist

Clinical social worker

Other nonphysician practitioners under the supervision of a physician

For permanent placement, include all the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s)

A successful trial should be associated with at least 50% reduction of target pain
   or
50% reduction of analgesic medications