Spinal Cord Stimulation / Dorsal Column Stimulation - (Effective Date - 2026-10-15) 7.01.51

By October 15, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization workflows to require documentation of all applicable criteria for each clinical indication (FBSS, PDPN, CRPS/RSD, CLI, or angina); (2) Develop pre-claim checklists for SCS trial procedures requiring: minimum conservative treatment duration (6 months for FBSS/CRPS/RSD; medication trials for PDPN), behavioral health provider attestation (face-to-face or virtual assessment), and clinical documentation per specific diagnostic criteria; (3) For PDPN cases, ensure HbA1c lab results (<10% within 3 months) and opioid dosing verification (≤100 MME/day) are attached to authorization requests; (4) For CLI cases, require vascular surgeon attestation of non-candidacy for reconstruction and imaging documentation (angiography, CT, or MRI showing multi-level disease); (5) For permanent implant authorizations, require documented trial results showing ≥50% pain relief before submission; (6) Update encounter forms and pre-authorization templates to capture behavioral health clearance status; (7) Train providers on the distinction between short-term trial requirements (FBSS: >48 hours; PDPN: ≥5 days; CRPS: >48 hours; CLI: >48 hours) and permanent implantation pathways. Failure to document all required criteria will result in claim denials. Claims submitted without prior authorization or lacking required documentation will be rejected.