Outpatient Department Prior Authorization Implanted Spinal Neurostimulators Alert

Implanted Spinal Neurostimulator Prior Authorization

National Government Services Medical Review initiated a prior authorization review outpatient department procedures for Implanted Spinal Neurostimulator on 7/1/2021.

Prior Authorization Reminder:

For Implanted Spinal Neurostimulator prior authorization, HCPCS 63650 is the only code that needs to be prior authorization for trial and permanent placement.

Documentation Requirements:

The general documentation requirements for Implanted Spinal Neurostimulator are as follows:

Indicate if this request is for a trial or permanent placement
Physician office notes including:
- Condition requiring procedure
- Physical evaluation
- Treatments tried and failed including but are not limited to:
  - Spine surgery
  - Physical therapy
  - Medications
  - Injections
  - Psychological therapy
Documentation of psychological evaluation
For permanent placement, include documentation of pain relief with a temporary implanted electrode
- A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.

Outpatient Department Prior Authorization Implanted Spinal Neurostimulators Alert

Implanted Spinal Neurostimulator Prior Authorization

Prior Authorization Reminder:

Documentation Requirements:

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