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Medicare (Traditional Part A & B) · spinal cord stimulation

v1verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 7 ticked
Indications
  • enumerated: no
  • description: chronic intractable pain; best suited to neuropathic pain
Conservative care
  • required: yes
  • satisfied by:
    • tried and unsatisfactory
    • judged unsuitable or contraindicated
  • modalities named:
    • pharmacologic
    • surgical
    • physical
    • psychological
  • min duration months: not stated in the policy
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: (pain_reduction OR med_reduction) AND functional_improvement
    • pain reduction pct: 50
    • med reduction pct: 50
    • functional improvement: required
  • threshold is binding: no
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: ordered at trial; pending; patient referred; result routed to authorization
Screening
  • multidisciplinary team: required
  • late or last resort: yes
Quantity limits
  • applies: no
Device / waveformagnostic
Payor-specific notes

Governed by NCD 160.7, not an LCD. The universally-expected documentation standard (>=50% pain or analgesic reduction + functional gain) derives from the Noridian/Palmetto LCDs and should still be documented though not formally binding here. Trial is the hurdle: once a trial is approved and successful, implant approval follows and is templated separately.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Every clinical assertion maps to an NCD 160.7 condition.

.SCSTRIALMCARE
.SCSTRIALMCARE

Assessment: *** — chronic intractable pain, predominantly neuropathic, involving the
___ region, present *** and refractory to treatment.

Medical necessity per Medicare NCD 160.7 (Electrical Nerve Stimulators): this patient has
been managed with pharmacologic therapy, physical therapy, and interventional treatment
including ESI / nerve blocks where appropriate — *** — with unsatisfactory response, or
these measures were contraindicated. Spinal cord stimulation is pursued as a late-resort
therapy. Multidisciplinary screening is complete; psychological evaluation was ordered at
the time of trial, the patient has been referred, and the result is pending and will be
forwarded to authorization. History, imaging, and screening documentation are on file.

Plan: Percutaneous SCS trial. Trial response — targeting >=50% reduction in target pain
and/or >=50% reduction in analgesic use with functional improvement — will be assessed and
documented to support permanent implantation. Risks, benefits, and alternatives discussed;
consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line
  • psych-eval line
  • conservative-care line

Cautions

  • The >=50% figure is the multi-MAC LCD documentation convention, not NCD 160.7 text — the policy records `threshold_is_binding: false`. Document it (protective), but it is not a hard NCD gate. NCD 160.7 sets no pain-duration floor and no imaging-pathology requirement — do not add numbers the record can't support. Regenerate if `medicare-in-ky-scs.md` `version` advances past `source_version` above.

Prior-auth pathway

  • required: yes
  • pathway: OPD prior auth list (hospital outpatient)

Provenance

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Change history

  • 2026-07-24scs/medicare: verified vs NCD 160.7 text (MCP) - criteria+dates match, no change; last_verified 2026-07-24 4c2b316c7b
  • 2026-06-27Seed: locked schema + SCS templated for Medicare (NCD 160.7) and Aetna (CPB 0194) 89cec9dbfe