Spinal Cord Stimulator Checklist


A Spinal cord stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain. The documentation requirements for trial or permanent Implanted spinal neurostimulators are included in this 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

   




Last Updated: 06/04/2021