Is a NEVRO (Spinal Cord Stimulation) trial with the diagnosis of radiculopathy, lumbosacral region, medically necessary?

Medical Necessity Determination for Nevro SCS Trial

Based on the insurer's clinical policy and available documentation, this Nevro SCS trial for lumbosacral radiculopathy cannot be certified as medically necessary at this time due to incomplete documentation of required criteria and a diagnosis that does not match the policy's covered indications.

Critical Documentation Gaps

The case fails to meet several mandatory criteria specified in the insurer's Clinical Policy Bulletin 0194:

Missing Psychological Clearance

• No formal clearance letter from a psychiatrist, psychologist, or qualified mental health professional is documented 1
• While a psychological evaluation date is listed (PAGE8) and mental health history is noted (PAGE34), the policy explicitly requires documented clearance, not just an evaluation 1
• The patient has documented anxiety, depression, and panic disorder (PAGE17), making formal clearance particularly important before proceeding 2

Unclear Multidisciplinary Evaluation

• The policy requires "careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation" 1
• Documentation shows pain medicine and surgical consultations but does not clearly demonstrate coordinated multidisciplinary team evaluation 2

Substance Use Disorder Screening Incomplete

• While toxicology screening protocols are referenced (PAGE21, PAGE26), there is no clear documentation that the patient has been formally evaluated and cleared for absence of untreated substance use disorders per ASAM guidelines 2
• Given the patient is on high-dose opioids (oxycodone, tramadol), this assessment is critical 2

Missing Functional Assessment

• No Oswestry Disability Index (ODI) score is documented, despite the policy requiring an ODI score ≥21% 1
• Functional disability must be objectively quantified before SCS trial 2

Insufficient Conservative Treatment Documentation

• The policy requires 6 months of failed conservative management including formal in-person physical therapy for minimum 6 weeks within the past year 1
• Documentation mentions "home exercise" and "physical therapy" but does not clearly specify formal, supervised, in-person physical therapy with a licensed therapist for the required duration 1, 3

Post-Surgical Timing Not Documented

• If the patient has had spinal surgery, the policy requires they be at least 6 months post-operative 1
• No documentation of surgical history or timing is provided

Diagnosis Mismatch Issue

The primary diagnosis of "radiculopathy, lumbosacral region" (M54.17) is not explicitly listed among the covered indications in the insurer's policy 1:

• The policy covers SCS for "chronic neuropathic pain of certain origins" including lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy (including diabetic peripheral neuropathy), post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy 1
• The policy also covers "persistent radicular pain" in the context of failed back surgery syndrome, but this case does not document prior back surgery 1, 4, 5
• While the clinical notes describe "painful diabetic neuropathy involving both upper and lower extremities" (PAGE11), the submitted diagnosis code is for radiculopathy, not diabetic peripheral neuropathy 3, 6, 7

Clinical Evidence Supporting SCS for Radiculopathy

Despite the administrative barriers, the clinical literature does support SCS for persistent radicular pain:

• The American Society of Anesthesiologists guidelines state that "spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies" 1
• SCS has demonstrated effectiveness for neuropathic pain, with randomized controlled trials showing superiority over conventional medical management and reoperation for failed back surgery syndrome 4, 5
• A screening trial should be performed before permanent implantation to allow patients to experience the therapy 2, 8

Recommendations for Case Resubmission

To achieve medical necessity determination, the following must be obtained and documented:

1. Formal written clearance from psychiatrist, psychologist, or qualified mental health professional specifically addressing suitability for SCS 1, 2

2. Completed Oswestry Disability Index with score documented (must be ≥21%) 1

3. Formal substance use disorder evaluation per ASAM guidelines with documentation of no untreated disorders 2

4. Clear documentation of multidisciplinary team evaluation including pain medicine, surgery, psychology, and physical therapy 2

5. Detailed physical therapy records showing formal, supervised, in-person therapy with licensed therapist for minimum 6 weeks within past year 1

6. Surgical history documentation if applicable, confirming at least 6 months post-operative 1

7. Consider diagnosis code revision to diabetic peripheral neuropathy if clinically appropriate, given the clinical notes describe "painful diabetic neuropathy" which IS a covered indication 1, 3, 6

8. Document poor glycemic control has been addressed, as the clinical note states HbA1c is elevated and endocrinology follow-up scheduled—this must be resolved before proceeding to minimize infection risk 1

Common Pitfalls to Avoid

• Do not proceed with SCS trial until psychological clearance is formally documented—this is a hard requirement, not optional 1, 2
• Do not assume a psychological evaluation is equivalent to psychological clearance—the policy requires explicit clearance 2
• Ensure the diagnosis code matches the clinical presentation and policy coverage—if this is truly diabetic neuropathy, code it as such 3, 6, 7
• Do not skip the ODI assessment—this objective measure is mandatory and helps establish baseline functional status 1
• Address glycemic control before any invasive procedure to minimize infection risk 1