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Outpatient Department Prior Authorization for Implanted Spinal Neurostimulators Alert

Implanted Spinal Neurostimulator Prior Authorization

National Government Services Medical Review initiated prior authorization reviews for the outpatient department procedure, 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.

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Posted 7/7/2021


Last Modified: 7/7/21
Outpatient Department Prior Authorization for Implanted Spinal Neurostimulators Alert
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