Prior Authorization Details

General Documentation Requirements for Trial or Permanent Implanted Spinal Neurostimulators

National Government Services will begin accepting PARs for Implanted Spinal Neurostimulators on 6/17/2021 for services provided beginning on or after 7/1/2021.

Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the UTN received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.

  • Indicate if the request is for trial or permanent placement
  • Physician office notes including:
    • Condition requiring procedure
    • Physical examination
    • Treatments tried and failed including but are not limited to:
      • spine surgery
      • physical therapy
      • medications
      • injections
      • psychological therapy
  • Documentation of appropriate psychological evaluation (see MLN® Booklet Medicare Mental Health and CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 for more information on psychological evaluations).
  • 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. 

Services associated with devices approved under an IDE study must undergo prior authorization and meet the coverage requirements in NCD 160.7.

This checklist is not all inclusive; please submit any additional medical records that help support the medical necessity of the HOPD service.

A facility or the beneficiary may submit the PAR and supplemental documentation via NGSConnex, esMD, fax or mail.

  • NGSConnex
  • Fax
    • JK: 317-841-4530
    • J6: 317-841-4528
  • Mail
    • National Government Services, Inc.
    • Attention: Medical Review Prior Authorization Request
    • P.O. Box 7108
    • Indianapolis, IN 46207-7108
  • Provider Contact Center Inquiry Line:
    • JK: 888-855-4356
    • J6: 877-702-0990

PAR decisions and the unique tracking numbers assigned for these services will be valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on 7/1/2021, the PAR will be valid for dates of service through 10/28/2021. Otherwise, the provider will need to submit a new PAR.