Utilization Review Checklist
Implantable Spinal Cord Stimulator for Low Back or Radicular Pain
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 63650, 63655, 63685, 63688. ICD-10 M54.16, M54.17, M96.1, 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.
Procedures — the guideline treats each separately
Implantable spinal cord stimulator for low back pain, radicular pain syndrome or failed back surgery syndrome
Not Recommended.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low
Presumptive Diagnosis
Required
Clear diagnosis of chronic radiculopathy with supportive evidence on electrodiagnostic study, and leg pain predominating over axial back pain
“Clear diagnosis of chronic radiculopathy including supportive evidence on electrodiagnostic study. Leg pain should predominate over axial back pain” — p. 181
Conservative Care
All of the following
Poor or inadequate response to surgical treatment such as discectomy
“Poor or inadequate response to surgical treatment such as discectomy.” — p. 182
AND
Poor or inadequate response to a functional restoration programme, generally for at least 6 months, in an experienced interdisciplinary clinic including progressive aerobic exercise, strengthening and cognitive behavioural therapy, with documented compliance — at least 6 months
“Poor or inadequate response to functional restoration program with treatment generally for at least 6 months.” — p. 182
AND
Remedial surgery inadvisable or not feasible
“Remedial surgery inadvisable or not feasible.” — p. 182
Confirmatory Diagnosis
All of the following
Major psychiatric disorders have been treated with expected responses
“Major psychiatric disorders have been treated with expected responses.” — p. 182
AND
Successful independent psychological evaluation by a psychologist specialising in chronic pain, not employed by the requesting or treating physicians
“The psychological evaluation should be performed by a practitioner who is not employed by the requesting or treating physicians.” — p. 182
AND
Willingness to stop inappropriate drug use before implantation
“Willingness to stop inappropriate drug use before implantation.” — p. 182
AND
No indication that secondary gain is directly influencing pain or disability complaints
“No indication that secondary gain is directly influencing pain or disability complaints.” — p. 182
AND
Ability to give informed consent for the procedure
“Ability to give informed consent for the procedure.” — p. 182
Surgical Considerations
Any one of the following
Implantable spinal cord stimulator
“Spinal cord stimulators are not recommended for treatment of acute, subacute, chronic low back pain, radicular pain syndromes or failed back surgery syndrome.” — p. 180
All of the following:
Successful trial of a temporary external stimulator with at least 50% pain reduction, and reduced opioid or other medication use, or functional improvement — at least 50
“Successful results of at least 50% pain reduction from a trial of a temporary external stimulator of approximately 2-3 days” — p. 182
AND
The guideline does not recommend this device, and Table 11's criteria do not change that
“Spinal cord stimulators are not recommended for treatment of acute, subacute, chronic low back pain, radicular pain syndromes or failed back surgery syndrome.” — p. 180
Not recommended. Table 11's nine selection criteria are the guideline's description of a highly select candidate, not a route to authorisation — the recommendation stands whether or not they are met. Document all nine anyway: they are what the request will be judged on, and criteria 3, 5 and 9 (six months of interdisciplinary functional restoration, an independent psychological evaluation, and a successful temporary trial) are the ones requests most often lack.