Spinal Cord Stimulator Checklist

Published 06/04/2021

A Spinal cord stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain. The documentation requirements for trial or permanent Implanted spinal neurostimulators are included in this checklist. 




Indicate if this request is for a trial or permanent placement


Documentation supports a specific condition indicated for neurostimulator placement



The implantation of the stimulator is used only as a late resort



Documentation that the specific risks and benefits of the procedure were discussed with the beneficiary



Documentation that alternatives and non-surgical options were discussed with the beneficiary



Clear documentation that the beneficiary desires surgical correction



Physician order for the procedure/device



Documentation supports that conservative treatments have been tried and failed

Pharmacological therapies


Surgical therapies


Physical therapies


Psychological therapies


Evaluation performed by a qualified professional





Clinical social worker


Other nonphysician practitioners under the supervision of a physician


For permanent placement, include all the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s)

A successful trial should be associated with at least 50% reduction of target pain
50% reduction of analgesic medications


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