Permanent SCS Implant is NOT Medically Indicated Until Formal Physical Therapy Documentation is Provided
Despite an excellent trial result (>80% pain relief), the patient does not meet medical necessity criteria because formal in-person physical therapy with a licensed physical therapist for a minimum of 6 weeks is required, with documentation including dates of service, specific interventions, patient response, and therapist assessment 1, 2. This is a non-negotiable requirement that must be satisfied before permanent implantation can be approved.
Critical Missing Documentation
Physical Therapy Requirement:
- The American Society of Anesthesiologists explicitly requires formal in-person physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year 1, 2
- Documentation must include: dates of service, specific interventions performed, patient response to treatment, and formal therapist assessment 1, 2
- The current record states "PARTLY MET - no formal PT noted," which is insufficient for medical necessity determination 1
- This requirement exists even when patients report medication side effects or reluctance to try additional therapies 1
Criteria Met That Support Future Approval
Successful Trial Performance:
- The patient achieved >80% pain reduction during the SCS trial, which far exceeds the required 50% threshold for permanent implantation 2, 3, 4
- A successful trial showing ≥50% pain relief is the strongest predictor of long-term success with permanent implantation 2, 5
- In FBSS patients, 47-59% achieve ≥50% pain relief at long-term follow-up; this patient's 80% trial response suggests excellent prognosis 2, 5
Appropriate Clinical Indication:
- The patient has chronic neuropathic pain with sensory motor axonal polyneuropathy confirmed by EMG/NCS, which is an established indication for SCS 1, 5
- New L5-S1 disc extrusion with caudal migration displacing the left S1 nerve correlates with her radicular symptoms 1
- Pain duration since the 1990s with progressive worsening meets the 12-month chronicity requirement 1
Psychological Clearance:
- Psychological evaluation completed with no significant problems precluding neurostimulation implant 1, 2
- No untreated substance use disorder documented 1, 2
- Patient demonstrates motivation through trial participation and reporting of functional improvements 1
Medication Trials:
- Gabapentin 600mg TID trialed without relief 1, 6
- Pregabalin (Lyrica) provided relief but discontinued due to abdominal swelling side effect 1, 6
- Nortriptyline 30mg nightly currently used without relief 1
- Lidocaine patches/cream and compound creams trialed without relief 1
- These trials satisfy the requirement for documented first-line neuropathic pain medication attempts 1
Interventional Procedures:
- Lumbar epidural steroid injection (LESI) performed, which addresses conservative treatment requirements 1
- The patient reports sciatica improved after epidural but neuropathy persists, demonstrating appropriate treatment progression 1
Oswestry Disability Index Discrepancy
Critical Issue with ODI Score:
- The documented ODI score is 15, which equals 30% disability (moderate disability category) 1, 2
- However, the insurance criteria require ODI ≥21% for medical necessity, and the note states this criterion is "MET" 1, 2
- An ODI score of 15 represents 30% disability, which does meet the ≥21% threshold 1, 2
- This apparent discrepancy should be clarified, but the 30% disability level does satisfy the functional impairment requirement 1, 2
Expected Outcomes Based on Trial Success
Pain Relief Durability:
- High-frequency SCS (10-kHz) demonstrates 76.5% of patients maintaining responder status (≥50% pain relief) at 24 months for back pain 3
- For leg pain, 72.9% maintain responder status at 24 months with high-frequency SCS 3
- This patient's >80% trial response suggests she will likely be among the sustained responders 2, 5
Functional Improvements:
- The patient reports improved ability to stand and walk greater distances with significantly less pain 2
- Reduction in swelling and discoloration in feet suggests improved circulation/function 2
- These functional gains align with expected ODI improvements seen in successful SCS patients 3, 7
Required Action Before Approval
Obtain Formal Physical Therapy Documentation:
- Schedule and complete a minimum 6-week course of formal in-person physical therapy with a licensed physical therapist 1, 2
- Ensure documentation includes: specific dates of all sessions, detailed interventions performed (e.g., therapeutic exercises, manual therapy, modalities), patient's response to each intervention, and formal therapist assessment of progress and functional limitations 1, 2
- Physical therapy should specifically address lower extremity neuropathic pain management, gait training, and functional mobility given her reported difficulty with sock/shoe donning 1
Common Pitfalls to Avoid
Documentation Completeness:
- Simply stating "patient tried PT" is insufficient; formal documentation from the physical therapist's office is required 1, 2
- Home exercise programs or informal recommendations do not satisfy this requirement 1
- The 6-week minimum must be clearly documented with specific dates 1, 2
Hardware-Related Risks:
- Lead migration occurs in 9% of cases and hardware-related complications occur in 10-29% of cases 1
- Infection risk is 10-29%, with wound dehiscence followed by infection occurring in 14% of cases 1
- These risks should be discussed with the patient, though her successful trial and lack of contraindications suggest acceptable risk profile 1, 5
Medication Expectations:
- SCS may reduce but not eliminate the need for analgesic medications 2
- Gabapentin has proven effectiveness for FBSS-related neuropathic pain and may be continued as adjunctive therapy despite her previous poor response 2
- The patient's medication side effects and reluctance to try additional medications does not waive the physical therapy requirement 1