Spinal Cord Stimulation / Dorsal Column Stimulation 7.01.51

REQUIREMENTS: By October 15, 2025: Billing and prior authorization teams must immediately implement this policy across all SCS-related claims processing: 1. PRIOR AUTHORIZATION PROCESS (All staff): Establish mandatory prior auth for ALL spinal cord stimulation and dorsal column stimulation cases before procedure scheduling. Create separate auth pathways for: (a) short-term trial SCS (>48 hours), and (b) permanent implantation. 2. DOCUMENTATION REQUIREMENTS (Providers & Clinical staff): Update encounter templates and referral forms to capture ALL required criteria before submitting for authorization: - For FBSS: Document 6+ consecutive months physician-supervised conservative management (pharmacotherapy, PT, cognitive therapy, lifestyle modification); surgical indication assessment; behavioral health face-to-face or virtual attestation ruling out uncontrolled mental health/substance use disorders - For CRPS/RSD: Verify anatomic limitation to extremities only; document all diagnostic criteria (disproportionate pain, 3+ symptom categories, 2+ physical exam sign categories, exclusion of other diagnoses); 6+ months conservative management; behavioral health clearance - For CLI: Obtain vascular surgeon attestation of non-candidacy for reconstruction; document Rutherford Grade II Category 4 with specific pressures (<40 mmHg ankle, <30 mmHg toe); provide advanced imaging showing multi-level disease; behavioral health attestation - For Angina: Confirm CCS Class III or IV; obtain cardiologist attestation of CAD diagnosis and non-candidacy for revascularization; document optimal medical therapy failure (anti-platelet, statin, anti-anginal with HR goal 60 bpm, anti-hypertensive with BP goals); behavioral health clearance 3. TRIAL OUTCOME TRACKING (Billing team): Prior to processing any permanent implant claims, require documentation of ≥50% pain reduction during short-term trial period. Create claim submission checklist requiring trial outcome documentation. 4. DEVICE REPLACEMENT RULES (Billing & Clinical): Apply replacement policy ONLY when: (a) existing device/battery is malfunctioning, non-repairable, out-of-warranty, OR (b) electrode revision is needed. Flag and DENY claims for high-frequency to high-frequency SCS upgrades (Statement VI). 5. SYSTEM UPDATES (Billing system administrator): - Add authorization code blocking for high-frequency SCS replacements of functioning devices - Create clinical decision support alerts in billing software requiring trial documentation for implant claims - Tag all SCS-related line items for mandatory behavioral health clearance verification 6. STAFF TRAINING (Practice management): Brief all front-desk, clinical, and billing staff on new 48-hour minimum trial requirement and permanent implant success criteria. Update insurance verification scripts to alert patients of behavioral health requirement. CONSEQUENCES: Claims submitted without prior authorization, complete conservative management documentation, behavioral health clearance, or adequate trial outcomes will be DENIED. Retroactive denials and recoupment may apply. High-frequency upgrades will be denied as non-medically necessary regardless of clinical presentation.