CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Spinal cord stimulation (implant) authorization form — Coverage criteria

Form and authorization requirements for spinal cord stimulation (SCS) implant procedures, including documentation and trial stimulation, for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpinal cord stimulation (implant) authorization form — Coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the Neighborhood form with supporting clinical documentation including a documented 3–7 day external spinal cord stimulation trial and results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-7 daysrequired trial duration with external generator

physician signature requiredmust be signed by treating physician

401-459-6023Utilization Management fax/phone for completed form

Updated 2/2016most recent document update

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization criteria for spinal cord stimulation implant

Covered when ALL of the following are provided and documented

Clinical indications: Documentation that patient has one or more qualifying conditions: radicular extremity pain from failed back surgery syndrome, damage to peripheral nerves, complex regional pain syndrome (reflex sympathetic dystrophy), arachnoiditis, or other listed neuropathic/intractable pain (e.g., headaches, neuralgia, phantom limb pain, post-herpetic neuralgia, intractable angina, diabetic neuropathy, cervical spine trauma/disc herniation/failed cervical spine syndrome).

List of conditions provided on form; include specific diagnosis.

Surgical candidacy: Indicate whether surgical intervention is an option for the patient (Yes/No). If No, provide reason why surgery is not an option.

Form requests surgical candidacy and rationale if not eligible.

Psychological evaluation: Documentation that the patient has undergone a psychological or psychiatric evaluation (Yes/No documented).

Form asks whether psych evaluation was performed.

Prior treatments documented: Submit clinical notes documenting previous treatments and outcomes, which may include medications, surgery, physical therapy, and/or psychological treatment.

Required to demonstrate conservative therapy attempts.

SCS trial documented: Documentation of a trial of spinal cord stimulation with an external generator for 3-7 days and the trial results must be submitted prior to approval for permanent implantation.3-7 days

Explicit trial duration required on form.

Administrative fields completed: Provider/supplier identification (Provider's name, Supplier ID or NPI), date of request/date of service, place of service/facility, PT/CPT codes and units, diagnosis, and provider contact information must be completed.

Administrative form fields required for processing.

Physician signature: Form must be signed and dated by the treating physician.

Signature requirement stated on form.

The form does not list any explicit exclusions. It focuses on documenting qualifying neuropathic or intractable pain conditions and required supporting information rather than enumerating procedures or diagnoses that are excluded from coverage.

An approved prior authorization on this form does not guarantee payment. The form explicitly states that authorization is not a guarantee of payment and documents the need for complete clinical information; it therefore provides no specific list of "not medically necessary" conditions on the form itself.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for spinal cord stimulation procedures. Submit the Neighborhood prior authorization form with supporting clinical documentation, including documentation of a successful trial stimulation (see trial requirement below). Return the completed form to the Utilization Management Department at (401) 459-6023. Refer to Neighborhood's Clinical Medical Policy on the Neighborhood website for full coverage criteria and authorization requirements.

Submit Neighborhood prior authorization form
Include supporting clinical documentation
Call Utilization Management at (401) 459-6023

Documentation Required

Trial Prior to Implant

Document a documented trial of spinal cord stimulation using an external generator for a duration of 3-7 days prior to consideration of permanent implant. Include trial stimulation results and clinical response in the submission.

Trial duration: 3-7 days
Include trial stimulation results and clinical response

Denial Risk

Authorization/Payment Disclaimer

Authorization is not a guarantee of payment. Lack of prior authorization or incomplete documentation (including missing trial results or clinical notes of prior treatments) may result in denial or delayed payment. Neighborhood’s decision block on the form notes: "Authorization is not a guarantee of payment."

Authorization is not a guarantee of payment
Incomplete or missing documentation may result in denial or delayed payment
Ensure trial results and prior treatment notes are submitted

Conservative Treatment Requirements

Document prior conservative therapies and outcomes

Conservative therapy history: Submit clinical notes documenting prior conservative treatments and outcomes, which may include trials of medications, prior surgeries, physical therapy, and psychological treatment.

Used to demonstrate that less invasive therapies were attempted and their results.

Treatment specifics: For each conservative therapy, include dates, duration, response (objective and subjective), and reason for discontinuation or failure.

Provide sufficient detail to assess adequacy of prior therapy attempts.

Background

This authorization form is intended for patients being considered for spinal cord stimulation (SCS) implant for chronic neuropathic or intractable pain (for example, radicular extremity pain from failed back surgery syndrome, peripheral nerve damage, complex regional pain syndrome/reflex sympathetic dystrophy, arachnoiditis, post‑herpetic neuralgia, phantom limb pain, diabetic neuropathy, intractable angina, and similar conditions). The form requests assessment of surgical candidacy, documentation of prior conservative therapies and psychological evaluation, and requires submission of results from a documented external generator trial of SCS lasting 3–7 days prior to consideration for permanent implantation.

PT Code	Physical therapy code field as requested on form
CPT Code	Procedure CPT code field as requested on form
Units	Units field for PT and CPT codes

OpenPayer

Spinal cord stimulation (implant) authorization form — Coverage criteria

Coverage Criteria

Requested Billing Codes

Provider Actions & Requirements

Conservative Treatment Requirements

Definitions

Imaging Requirements

Frequency Limits

Background