Utilization Review Checklist
Spinal Cord Stimulator for Chronic Cervicothoracic Pain
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 63650, 63655, 63685, 63688. ICD-10 M54.2, M54.6, M54.12, G89.4.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis(informational — not scored)
Required
Chronic cervicothoracic pain, with or without radiculopathy
“Spinal cord stimulators are not recommended for chronic cervicothoracic pain with or without radiculopathy.” — p. 116
Procedures — the guideline treats each separately
Implantable spinal cord stimulator for chronic cervicothoracic pain, with or without radiculopathy
Not Recommended. Spinal cord stimulators are not recommended for chronic cervicothoracic pain with or without radiculopathy.
Strength of Evidence — Not Recommended, Insuffcient Evidence (I) · confidence low · p. 116
Indications — required:
The guideline advises against spinal cord stimulators for chronic cervicothoracic pain, with or without radiculopathy
“Spinal cord stimulators are not recommended for chronic cervicothoracic pain with or without radiculopathy.” — p. 116
Not recommended, with or without radiculopathy. The Low Back chapter's Table 11 selection criteria belong to the lumbar recommendation and are not restated here — but a reviewer may well look for them, so documenting the equivalent is prudent even though this chapter does not ask.