Skip to Main Content

Print | Bookmark | Email | Font Size: + |

Spinal Neurostimulators

OPD Procedure: Implanted Spinal Neurostimulator

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 Unique Tracking Number (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 a hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.

Medical Necessity

Services are considered reasonable and medically necessary in patients who meet one or more of the following:

  • Late/last resort for patients with chronic intractable pain
  • Other treatment modalities have proven to be unsuccessful:
    • Past surgeries,
    • Pharmacological,
    • PT/OT therapy interventions,
    • Psychological therapies,
    • Judged to be unsuitable/contraindicated – need to have documentation indicating why
  • Demonstration of pain relief with a temporary implant

General Documentation Requirements

  • Clinical evaluations related to the patient’s pain
  • Current H&P, office visit notes/progress notes
  • Psychological evaluation conducted by a psychiatrist, clinical psychologist, or a licensed medical social worker
  • Documentation related to previous conservative treatments tried
  • If applicable, documentation indicating why conservative treatments could not be tried
  • Documentation on how their pain affects their ADLs
  • For permanent placement, documentation showing the trial resulted in significant reduction in pain or in analgesic use

Prior Auth Request Form

Prior Authorization OPD: Implanted Spinal NeurostimulatorsPDF

Coverage Criteria and Resources


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved