Clinical Review Criteria Update – Spinal Cord Stimulation
Posted on March 30, 2021
Policy Number: UM300POL
Effective Date: 6/1/2021
LOB Affected: Commercial, Medicare, Medicaid
Policy Type: Medical
Definitions
Added Nociceptive Pain and Spinal Cord Stimulator
• I., Criteria for Approval
B.
o Added #2.
o Changed 4:
From:
The treatment is a last resort, for chronic conditions with documentation of > 12 months of ineffective treatment and when the pain is refractory to all other therapies(pharmacologic, surgical, psychological, and physical, when appropriate) or the therapies are considered unsuitable or contraindicated; and
To:
The treatment is a last resort, for chronic conditions with documentation of > 12 months of ineffective treatment and when the pain is refractory to all other therapies (pharmacologic, surgical, psychological, and physical therapy, when appropriate) or the therapies are considered unsuitable or contraindicated; and
o Added #7.
• II., Criteria for Approval for Medicare Members with below Medicare Links:
This section was added, and the remaining sections were re-numbered.
• IV., What is Not Covered
A.: Added #6.
• V., The following are considered investigational/experimental:
Deleted the original F., G., and H.:
A. Post amputation pain (phantom limb pain)
B. Post herpetic neuralgia
C. Peripheral neuropathy
• CPT Codes: Added 63685
• Updated all references.
