**Background**  
  
The implantation of spinal cord stimulators (SCS) may be covered as therapies
for the relief of chronic intractable pain. SCS is best suited for neuropathic
pain, but may have some limited value in other types of nociceptive severe,
intractable pain. Therapy consists of a short trial with a percutaneous
implantation of neurostimulator electrode(s) in the epidural space for
assessing a patient's suitability for ongoing treatment with a permanent
surgically implanted nerve stimulator. Performance and documentation of an
effective trial is a prerequisite for permanent nerve stimulation.  
  
Selection of patients for implantation of SCS is critical to success of this
therapy. SCS therapy should be considered as a late option after more
conservative attempts, such as medications, physical therapy, psychological
therapy or other modalities have been tried.  
  
Patients must have undergone careful screening, evaluation and diagnosis by a
multidisciplinary team prior to implantation. (Such screening must include
psychological, as well as, physical evaluation). Documentation of the history
and careful screening must be available in the patient chart if requested.  
  
Many experts recommend that the temporary neurostimulator be placed in an
Ambulatory Surgical Center (ASC) or outpatient hospital setting. However, the
temporary neurostimulator trial can be done in an office setting if all the
sterility, equipment, professional training and support personnel required for
the proper surgery, and follow up of the patient are available. Permanent
neurostimulators must be placed in an ASC or hospital. Physicians performing
SCS trials in the office setting must have like privileges at a local hospital
or ASC, or the providers must be subspecialty boarded in Pain Medicine by the
American Board of Anesthesiology.  
  
It is preferable that physicians performing the SCS trial will also perform
the permanent implant. If the physician implanting the trial neurostimulator
does not or cannot implant the permanent neurostimulator, the patient should
be informed of this in writing and given the name of the referral surgeon, who
will implant the permanent neurostimulator(s). It is expected that accurate
patient selection will lead to most patients going on to receive permanent
implants.  
  
Only patients who experience a positive response to a trial should proceed to
a permanent implantation. All trials which proceed to permanent implant must
have adequate documentation in the chart to support that decision. A
successful trial should be associated with at least a 50% reduction of target
pain, or 50% reduction of analgesic medications, and show some element of
functional improvement. (Patients with reflex sympathetic dystrophy may show
lower levels of improvement, since it takes longer periods for improvement
than the typical 1 to 2 week trial). Physician judgment and experience will
also be taken into account. Physicians with a low trial to permanent implant
ratio (less than 50%) may/can/will be subject to post-payment review and may
be asked to submit documentation as to the patient selection criteria, the
radiologic imaging demonstrating proper lead placement, and the medical
necessity of the trials. Failure to provide this documentation will be cause
for post-payment denial and recoupment of reimbursement. It is understood that
all patients may not have a favorable result of the trial implant; but careful
selection should find the most appropriate patients.