Is permanent placement of a spinal cord stimulator (63655, 63685) medically necessary for a 64-year-old patient with postlaminectomy syndrome and chronic pain, who has failed conservative treatment and experienced 50% relief during a percutaneous spinal cord stim trial?

Permanent Spinal Cord Stimulator Implantation is Medically Necessary

This patient meets all established criteria for permanent spinal cord stimulator implantation and should proceed with the requested procedure (CPT 63655,63685). 1, 2, 3

Rationale for Medical Necessity

All Core Criteria Are Satisfied

Failed Back Surgery Syndrome with Documented Conservative Treatment Failure:

• The patient has postlaminectomy syndrome with persistent right-sided leg pain despite prior L3 laminectomy 2, 3
• Multiple failed interventions documented: epidural injections, radiofrequency ablation (RFA), and trials of gabapentin, tramadol, cyclobenzaprine, meloxicam, and tizanidine 1, 3
• Pain severity remains 8/10 with significant functional limitations affecting daily activities, sitting, standing, walking, driving, and sleeping 2

Successful Trial Stimulation:

• The patient achieved 50% pain relief during the percutaneous trial, meeting the threshold established by the American Society of Anesthesiologists for permanent implantation 1, 3
• Functional improvements documented: better sleep, easier mobility, and patient satisfaction ("thrilled" with relief) 3
• This 50% threshold is the standard benchmark across multiple guidelines for proceeding to permanent implantation 1, 3, 4

Favorable Psychological Evaluation:

• Psychological assessment reveals only mild-to-moderate adjustment disorder with mixed emotional features and a memory disorder NOS 3
• The evaluating psychologist explicitly supports candidacy, stating depression and anxiety are "mild enough to not interfere with a valid trial" 3
• The stipulation regarding family member assistance with device operation addresses the memory concern appropriately 3

Addressing the Two "Unsure" Criteria

Patient Capability to Operate Device

This concern is adequately mitigated and should not preclude approval:

• The psychological evaluation specifically addresses this issue with a practical solution: having the patient's family member learn device operation 3
• This accommodation is reasonable and commonly implemented in clinical practice for patients with cognitive limitations
• The patient successfully completed the trial period, demonstrating basic ability to tolerate and benefit from the therapy 3
• The American Society of Anesthesiologists requires psychological clearance to assess "device management capability," which has been obtained with appropriate accommodations 3

Coagulopathy and Anticoagulation Status

The absence of documented coagulation status is a documentation gap, not a contraindication:

• No anticoagulant or antiplatelet medications are listed in the patient's current medication regimen (gabapentin, tramadol, cyclobenzaprine, meloxicam, tizanidine) 3
• The patient successfully underwent percutaneous trial lead placement without documented bleeding complications, suggesting no significant coagulopathy 3
• Standard pre-operative clearance will address coagulation parameters before the permanent implantation procedure
• This is a correctable documentation issue that does not negate the overall medical necessity

Evidence Supporting SCS for Postlaminectomy Syndrome

Spinal cord stimulation is specifically indicated for failed back surgery syndrome:

• The American Society of Anesthesiologists strongly supports SCS for persistent radicular pain and postlaminectomy syndrome 1, 3
• Evidence demonstrates SCS provides better pain control than reoperation for patients with chronic back pain and radicular symptoms 2
• A systematic review found high-quality evidence (Level 2) that SCS decreases pain and Level 3a evidence that it improves functional status and quality of life in neuropathic pain conditions 4
• Patient satisfaction rates of 69-78% have been reported for SCS in patients with predominant low back pain complaints 5

Common Pitfalls and Caveats

Hardware-Related Complications:

• Technical failure rates approximate 11%, including lead migration and malposition 4
• Infection rates of 1.2% and other procedural complications should be discussed during informed consent 4
• Regular follow-up is essential as some patients experience diminishing effectiveness over time 6, 2

Pre-Operative Requirements:

• Confirm coagulation parameters (platelet count >75,000/mm³, no active anticoagulation) before surgery 3
• Ensure family member training on device operation is completed given documented memory disorder 3
• Consider formal cognitive testing as recommended by the psychologist to better characterize memory deficits 3

Post-Implantation Management:

• Continue medication monitoring and potential adjustment following implantation 6
• Schedule regular follow-up for device programming optimization 2
• Monitor for hardware complications, particularly in the first 6-12 months 4

Clinical Decision Algorithm

Proceed with permanent implantation when ALL are present:

1. ✓ Failed back surgery syndrome with chronic neuropathic pain
2. ✓ Failed conservative treatments (medications, injections, RFA)
3. ✓ Successful trial with ≥50% pain relief
4. ✓ Favorable psychological evaluation
5. ✓ Device operation capability (with accommodations if needed)
6. ✓ No absolute contraindications (verify coagulation status pre-operatively)

This patient satisfies all criteria with appropriate accommodations for the memory disorder. 1, 2, 3