Is spinal cord stimulator implantation medically indicated for a patient with chronic upper back and left shoulder pain due to facet-mediated thoracic spondylosis?

Non-Certification Recommended for Spinal Cord Stimulator Replacement

This spinal cord stimulator replacement request should be non-certified because the patient does not meet the insurer's medical necessity criteria, specifically lacking documented formal in-person physical therapy within the past year and missing a current Oswestry Disability Index (ODI) score ≥21%.

Critical Missing Documentation

Physical Therapy Requirements Not Met

• The insurer's CPB 0194 explicitly requires "formal in-person (not virtual) physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year" 1, 2
• The case history shows physical therapy was non-certified in a prior authorization (97014 x18, 97112 x2, 97140 x2, 97530 x20) for dates of service that are not specified as being within the past year 1, 2
• Another physical therapy request (97140 x14, 97530 x14) was certified but the dates of service are redacted, making it impossible to verify the 6-week minimum within the past year requirement 1, 2
• No documentation exists showing dates of service, specific interventions performed, patient response to therapy, or therapist assessment as required by the American Society of Anesthesiologists guidelines 3, 2

Missing Functional Disability Assessment

• The insurer requires "member's functional disability assessed using the Oswestry Disability Index (ODI); member has received an ODI score greater than or equal to 21%" 1, 2
• No current ODI score is documented anywhere in the submitted clinical records 1, 2
• The behavioral assessment on page 9 includes NIDA, PHQ-9, DASS-21, and Pain Catastrophizing Scale, but conspicuously omits the ODI 1, 2
• Without a baseline ODI ≥21%, medical necessity cannot be established per the insurer's explicit criteria 1, 2

Psychological Clearance Documentation Inadequate

• While page 10 states "no significant psychological barriers identified; candidate deemed appropriate," this does not constitute formal clearance from a psychiatrist, psychologist, or qualified mental health professional as required 3, 2
• The insurer requires "clearance from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Master of Social Work in behavioral health)" 3, 2
• The MMPI was reviewed on a redacted date (page 40), but no formal clearance letter or documentation from a mental health professional is included 3, 2

Diagnosis-Specific Concerns

Facet-Mediated Pain vs. Neuropathic Pain Indication

• The clinical documentation describes "facet-mediated thoracic spondylosis" as the primary diagnosis (page 18) 3
• The American Society of Anesthesiologists guidelines state that spinal cord stimulation is indicated for persistent radicular pain in patients who have not responded to other therapies 3
• The insurer's CPB 0194 lists SCS as appropriate for "chronic neuropathic pain" including conditions like peripheral neuropathy, post-herpetic neuralgia, and incomplete spinal cord injury—not facet-mediated pain 3
• The patient's chief complaint is "chronic upper back and left shoulder pain" radiating to ribs and armpits, which is more consistent with facet syndrome than the neuropathic radicular pain for which SCS has established efficacy 3

Failed Conservative Treatment for Facet Pain

• For facet-mediated thoracic pain, the 2023 PM&R guidelines recommend radiofrequency ablation after positive medial branch blocks, not spinal cord stimulation 3
• The patient had bilateral thoracic facet blocks (T4-5, T5-6, T6-7) with >80% pain relief initially (page 21), but follow-up showed <50% relief (page 22) 3
• No documentation of radiofrequency ablation being attempted despite this being the evidence-based next step for facet-mediated pain 3
• The 2010 ASA guidelines support intraarticular facet joint injections for symptomatic relief of facet-mediated pain, but do not endorse SCS for this indication 3

Device Replacement vs. New Indication

End-of-Life Device Consideration

• The current device (implanted on a redacted date) is described as "inactive due to end-of-life" (page 37) 4, 5
• The plan states "candidate for replacement; retrial required with >50% relief before permanent implant" (page 37) 3, 1
• This is technically a replacement procedure, but the insurer's criteria require meeting all initial implantation requirements including the trial period with >50% relief 3, 1

Trial Period Documentation Missing

• The insurer requires "a trial of percutaneous dorsal column stimulation to predict whether a dorsal column stimulator will induce significant pain relief" 3, 1
• The American Society of Anesthesiologists explicitly states "a spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device" 3
• No documentation of a recent trial period with documented >50% pain relief is included in the submitted records 3, 1
• The plan mentions "retrial required" but authorization is being requested before this trial has been completed 3, 1

Conservative Treatment Documentation Gaps

Medication Trials

• The insurer requires "other more conservative methods of pain management have been tried and failed for a minimum of 6 months (including non-steroidal anti-inflammatory drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and anticonvulsants)" 3, 2
• Page 18 lists systemic medications tried: multiple medications are redacted, making it impossible to verify adequate trials of the required medication classes 3, 2
• No documentation of specific dosages, duration of trials, or reasons for discontinuation of each medication class 3, 2
• The American Society of Anesthesiologists requires documented trials of first-line neuropathic pain medications (gabapentin, pregabalin, duloxetine, or tricyclics) before SCS 2, 6

Psychological Therapies

• The insurer requires that "psychological therapies" have been tried and failed 3, 2
• No documentation of cognitive behavioral therapy, pain psychology interventions, or other psychological pain management approaches is included 3, 2
• The behavioral assessment (page 9) documents pain catastrophizing and depression screening but does not document treatment attempts 3, 2

Procedural Code Concerns

Excessive Electrode Count

• The request is for L8680 x16 (16 electrodes) 3, 1
• The insurer's CPB 0194 states "up to 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead for a trial of a dorsal column stimulator" 3, 1
• While 16 electrodes is technically within the maximum allowed, this represents the absolute upper limit and requires strong justification 3, 1
• No clinical documentation explains why 16 electrodes are medically necessary for this patient's pain distribution 3, 1

Bilateral Placement Justification

• The request includes 63650 x2 (bilateral percutaneous implantation) 3
• The patient's pain is described as "chronic upper back and left shoulder pain" with radiation to ribs and armpits 3
• Predominantly unilateral left-sided pain does not clearly justify bilateral electrode placement 3

Recommendations for Resubmission

Required Documentation

• Obtain and document current ODI score ≥21% to establish functional disability per insurer criteria 1, 2
• Complete formal in-person physical therapy with a licensed physical therapist for minimum 6 weeks, with documentation including specific dates of service, interventions performed, patient response, and therapist assessment 1, 2
• Obtain formal psychological clearance letter from a psychiatrist, psychologist, or qualified mental health professional (MSW in behavioral health) explicitly stating the patient is appropriate for SCS implantation 3, 2
• Document specific medication trials including drug names, dosages, duration of adequate trials (minimum 6 months total), and reasons for discontinuation or failure for each required class: NSAIDs, tricyclics, SSRIs, SNRIs, and anticonvulsants 3, 2

Alternative Treatment Pathway

• Consider radiofrequency ablation of thoracic medial branches as the evidence-based next step for facet-mediated thoracic pain after positive diagnostic blocks 3
• The 2023 PM&R guidelines support RF procedures for facet-mediated pain after positive medial branch blocks, with 14 recommendations weakly or strongly in favor 3
• This approach is more aligned with the patient's documented diagnosis of facet-mediated thoracic spondylosis 3

Trial Period Requirement

• Complete a formal SCS trial period with documented >50% pain relief before requesting permanent implantation 3, 1
• The trial should use validated pain scales (VAS) and functional assessments to objectively document response 3, 1
• Only after successful trial completion should permanent implantation be requested 3, 1

Common Pitfalls to Avoid

Assuming Device Replacement Bypasses Initial Criteria

• Even though this is a device replacement due to end-of-life, all initial medical necessity criteria must be re-established 3, 1
• The insurer's policy does not distinguish between initial implantation and replacement regarding documentation requirements 3, 1
• A new trial period is explicitly mentioned as required (page 37) but has not been completed 3, 1

Confusing Facet Pain with Neuropathic Pain

• Facet-mediated pain and neuropathic radicular pain are distinct entities with different treatment algorithms 3
• SCS has established efficacy for neuropathic radicular pain, not mechanical facet-mediated pain 3
• The patient's diagnosis and pain pattern are more consistent with facet syndrome, for which RF ablation is the evidence-based intervention 3

Incomplete Documentation of Conservative Treatment Failures

• Simply listing medication names without dosages, durations, and reasons for discontinuation is insufficient 3, 2
• Physical therapy notes from prior authorizations do not substitute for current documentation within the past year 1, 2
• Psychological screening tools (PHQ-9, DASS-21) do not substitute for formal clearance from a mental health professional 3, 2