The coverage for payment of the service is predetermined before services are rendered and any deficiency of coverage by an insurance plan can be addressed prospectively, although it is not required.

Preauthorization is a required process that allows a patient and providers the opportunity to determine coverage and procure an authorization or approval from a payor for a proposed treatment or service prior to performing the service. Unfortunately, preauthorization does not guarantee reimbursement.

Despite painstaking efforts [2–5] of these therapies to be positioned earlier in the algorithm than last resort, the NCD [6] for spinal cord stimulation (dorsal column stimulation) requires all these below conditions are met:

The indications for spinal cord stimulation, on-label, by the Food and Drug Administration (FDA) are neuropathic pain of the trunk or limbs.

The LCD for Spinal Cord Stimulation in Northern California, covered by Noridian [6, 7], is code L33489. Interesting components of the code are bolded.

The implantation of spinal cord stimulators (SCS) may be covered as therapies for the relief of chronic intractable pain. SCS is best suited for neuropathic pain but may have some limited value in other types of nociceptive severe, intractable pain. Therapy consists of a short trial with a percutaneous implantation of neurostimulator electrode(s) in the epidural space for assessing a patient’s suitability for ongoing treatment with a permanent surgically implanted nerve stimulator. Performance and documentation of an effective trial is a prerequisite for permanent nerve stimulation.

Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. SCS therapy should be considered as a late (if not last) resort after more conservative attempts such as medications, physical therapy, surgery, psychological therapy, or other modalities have been tried.

Patients must have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological as well as physical evaluation.) Documentation of the history and careful screening must be available in the patient chart if requested. Patients being selected for a trial

Many experts recommend that the temporary neurostimulator be placed in an ASC or outpatient hospital setting. However, the temporary neurostimulator trial can be done in an office setting if all the sterility, equipment, professional training, and support personnel required for the proper surgery and follow-up of the patient are available. Permanent neurostimulators must be placed in an ASC or hospital . Physicians performing SCS trials in the office setting must have like privileges at a local hospital or ASC, or the providers must be subspecialty boarded in Pain Medicine by the American Board of Anesthesiology.

It is preferable that physicians performing the SCS trial will also perform the permanent implant. If the physician implanting the trial neurostimulator does not or cannot implant the permanent neurostimulator, the patient should be informed of this in writing and given the name of the referral surgeon who will implant the permanent neurostimulator(s).

It is expected that accurate patient selection will lead to most patients going on to receive permanent implants. Only patients who experience a positive response to a trial should proceed to a permanent implantation. All trials which proceed to permanent implant must have adequate documentation in the chart to support that decision. A successful trial should be associated with at least a 50 % reduction of target pain, or 50 % reduction of analgesic medications, and show some element of functional improvement. (Patients with reflex sympathetic dystrophy may show lower levels of improvement since it takes longer periods for improvement than the typical 1–2-week trial.) Physician judgment and experience will also be taken into account.

Physicians with a low trial-to-permanent implant ratio (less than 50 %) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a favorable result of the trial implant; but careful selection should find the most appropriate patients.

Noridian will reimburse for placement of a maximum of 2 leads or 16 “contacts,” and for 2 SCS trials per anatomic spinal region per patient per lifetime.

If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal.