SCS for low back pain

[painfree23]

What diagnosis codes (for insurance/ Medicare approval) do you use for the 80+ year old, non surgical patient with severe arthritis, severe multilevel stenosis, cauda equines impingement, never had surgery/not offered surgery because of age but wants to try SCS? I think it’s perfectly reasonable to offer this to patients but running into insurance companies who don’t think so because “patient never had back surgery” or doesn’t have “crps”?

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[Orin]

What diagnosis codes (for insurance/ Medicare approval) do you use for the 80+ year old, non surgical patient with severe arthritis, severe multilevel stenosis, cauda equines impingement, never had surgery/not offered surgery because of age but wants to try SCS? I think it’s perfectly reasonable to offer this to patients but running into insurance companies who don’t think so because “patient never had back surgery” or doesn’t have “crps”?

It depends on your region, but some allow for SCS "To treat intractable pain caused by cauda equina injury"

In general, they all allow SCS for "chronic intractable pain" that is refractory to conventional therapies

I would use a diagnosis of "lumbar stenosis with neurogenic claudication," document they're not a fixative surgical candidate due to patient or surgeon preference, document failure of conservative therapies/medications/injections, document MRI T spine showing space, and a permissive psych eval.

 

[nopain1234]

nm

 

[painfree23]

It depends on your region, but some allow for SCS "To treat intractable pain caused by cauda equina injury"

In general, they all allow SCS for "chronic intractable pain" that is refractory to conventional therapies

I would use a diagnosis of "lumbar stenosis with neurogenic claudication," document they're not a fixative surgical candidate due to patient or surgeon preference, document failure of conservative therapies/medications/injections, document MRI T spine showing space, and a permissive psych eval.

How do you diagnose cauda equina injury?

 

[lobelsteve]

How do you diagnose cauda equina injury?

Put in scs. If it works, say they had cauda equina injury.

 

[Orin]

How do you diagnose cauda equina injury?

I mean there are research criteria but it's a clinical diagnosis of pain/sensory/functional changes in the caudal beyond a single nerve root.

Cauda equina syndrome—a practical guide to definition and classification

International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes.We reviewed ...

www.ncbi.nlm.nih.gov

Do they have signs of CE nerve root clumping in MRI? Do those symptoms transcend a monoradic? Is there urinary retention or another functional/sensory deficits?

There are a ton of CMS covered reasons, but I highlighted that one was it appeared to fit your history and doesn't require surgery to have been done.

 

[SC Tian]

I use chronic pain syndrome as first diagnosis, radic as second if it exists.

 

[painfree23]

This is what my LCD says. These 10 diagnoses. This is it. Nothing about radiculopathy.

 

[Ducttape]

well...

do an epidural, then ask for auth for nerve root injury post-traumatic.

 

[unchockey21]

mild, Vertiflex, SCS (for the failed “surgeries”). It’s the pain equivalent of gym, tan, laundry.

 

[Agast]

If this is a Medicare patient that truly no surgeon wants to touch, I would do MILD first if there is ligamentum flavum hypertrophy. I haven’t really seen good long term SCS relief on virgin spines. During the trial they’ll talk themselves into 50% relief and then you’ll do the implant and find yourself reprogramming it over and over to try to capture the 50% that was actually 15%…

 

[MitchLevi]

I do not like "pre-op" SCS.

Severe stenosis doesn't respond well to SCS in my experience. I denied one yesterday for the same issue. Guy asked for one bc his neighbor has one. My pt has severe spinal stenosis L3-5.

I don't see how the MoA of SCS treats that pathophysiology.

Likewise, facet dz refractory to RFA by definition won't work.

SCS doesn't treat spondy.

 

[paindoc007]

If this is a Medicare patient that truly no surgeon wants to touch, I would do MILD first if there is ligamentum flavum hypertrophy. I haven’t really seen good long term SCS relief on virgin spines. During the trial they’ll talk themselves into 50% relief and then you’ll do the implant and find yourself reprogramming it over and over to try to capture the 50% that was actually 15%…

Meld. Minimally effective lumbar decompression. Superb idea

 

[painfree23]

I do not like "pre-op" SCS.

Severe stenosis doesn't respond well to SCS in my experience. I denied one yesterday for the same issue. Guy asked for one bc his neighbor has one. My pt has severe spinal stenosis L3-5.

I don't see how the MoA of SCS treats that pathophysiology.

Likewise, facet dz refractory to RFA by definition won't work.

SCS doesn't treat spondy.

I don’t see the problem with trying SCS trial instead of offering nothing.

 

[MitchLevi]

I don’t see the problem with trying SCS trial instead of offering nothing.

Can you explain why it would work?

 

[Ferrismonk]

What diagnosis codes (for insurance/ Medicare approval) do you use for the 80+ year old, non surgical patient with severe arthritis, severe multilevel stenosis, cauda equines impingement, never had surgery/not offered surgery because of age but wants to try SCS? I think it’s perfectly reasonable to offer this to patients but running into insurance companies who don’t think so because “patient never had back surgery” or doesn’t have “crps”?

If there is no radiculopathy or neurogenic claudication and your patient only has axial low back pain, you really shouldn't do SCS.

Unfortunately Vertiflex and MILD won't really help severe SS either.

If you or the patient really want to try SCS, just tell the truth and see what the insurance says. I would document the MRI findings, the severe stenosis with cauda equina impingement in particular, the limits on the patient's ADLs, what the patient has already tried and failed, as well as a surgeons note stating the patient is not a surgical candidate and a glowing psychological clearance letter. See what happens. If they say no, cash pay or payment plan is the only other option.

 

[Baron Samedi]

Can you explain why it would work?

Apparently BurstDR sends ascending signals to the brain to modulate our perception of suffering. Or so they say...

 

[MitchLevi]

Apparently BurstDR sends ascending signals to the brain to modulate our perception of suffering. Or so they say...

I've heard that...Was even told by an Abbott rep, "It's the affective component of pain, so even if they still hurt, they don't really care."

 

[Orin]

Can you explain why it would work?

https://www.empr.com/home/news/senza-scs-system-approval-expanded-to-include-nonsurgical-refractory-back-pain/

Well the FDA seems to think SCS works based on these data.

High-Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Nonsurgical Refractory Back Pain: Design of a Pragmatic, Multicenter, Randomized Controlled Trial - PubMed

This large multicenter RCT will provide valuable evidence to guide clinical decisions in NSRBP.

pubmed.ncbi.nlm.nih.gov

 

[Orin]

This is what my LCD says. These 10 diagnoses. This is it. Nothing about radiculopathy.

Item #2: How do you define a nerve root injury vs a radiculopathy? Are you reading that to suggest you'd only accept traumatic nerve root disorders or injuries, such those from surgery or trauma associated?

 

[10KHertz]

Rarely will you see a retraction of
Payment for severe radiculopathy , stenosis , central pain syndrome , etc.
They will retract money if no psych clearance.
Remember there is a push for once in a lifetime scs trial and implant/per patient. Revisions are allowed . So choose patient and device company appropriately IMO.

 

[MitchLevi]

https://www.empr.com/home/news/senza-scs-system-approval-expanded-to-include-nonsurgical-refractory-back-pain/

Well the FDA seems to think SCS works based on these data.

High-Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Nonsurgical Refractory Back Pain: Design of a Pragmatic, Multicenter, Randomized Controlled Trial - PubMed

This large multicenter RCT will provide valuable evidence to guide clinical decisions in NSRBP.

pubmed.ncbi.nlm.nih.gov

Dude...

Nevro published that POS.

Nevro is saving the world from both diabetic neuropathy and nonoperative low back pain.

...except in my pts of course. It fails them.

 

[painfree23]

Item #2: How do you define a nerve root injury vs a radiculopathy? Are you reading that to suggest you'd only accept traumatic nerve root disorders or injuries, such those from surgery or trauma associated?

That’s a great point. Thanks. I always assumed it was traumatic but a radiculopathy is definitely a nerve root injury and hard to argue it’s not . Thanks.

 

[Orin]

Dude...

Nevro published that POS.

Nevro is saving the world from both diabetic neuropathy and nonoperative low back pain.

...except in my pts of course. It fails them.

I'm with you bud.

I regretted having to refer to them, but they have the data here and ran the RCT for non-op back pain. The FDA bought in, and they're not known for being a pushover with this type of stuff.

I'm still trying to figure out why these amazing results haven't been published in a journal though.

 

[clubdeac]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

 

[callmeanesthesia]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

Who is covering it? I’d be interested but it seems excluded from all the payor contracts.

 

[MitchLevi]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

I've done one case of this.

Didn't work for us.

 

[lobelsteve]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

You need to publish. On Twitter, linkedin, and instagram.

 

[Ferrismonk]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

I still don't understand why this should work when RF doesn't.

 

[MitchLevi]

I still don't understand why this should work when RF doesn't.

Some ppl aren't any good at RFA

 

[clubdeac]

I still don't understand why this should work when RF doesn't.

They say the muscle stim actually activates several levels. I believe the theory has more to do with reversing some of the nociceptive aberrant signals through continuous muscle activation rather than blocking pain transmission from painful joints. Idk…the longer I practice the more I realize pain is too complex for me to understand

 

[bedrock]

They say the muscle stim actually activates several levels. I believe the theory has more to do with reversing some of the nociceptive aberrant signals through continuous muscle activation rather than blocking pain transmission from painful joints.

I'm not buying it, unless they do a direct, prospective comparative study (with a decent n )of this vs lumbar RFA with strict SIS technique.

 

[gdub25]

Item #2: How do you define a nerve root injury vs a radiculopathy? Are you reading that to suggest you'd only accept traumatic nerve root disorders or injuries, such those from surgery or trauma associated?

This is how I and most of my personal colleagues view it as well. Postlaminectomy is often pain from epidural fibrosis compressing the nerve root. Not much different than degen spine with compression of the nerve root exiting the foramen. Agree that results aren’t very good for spinal stenosis but we offer SCS in patients with low back, buttock pain who have MRI showing nerve impingement and surgery not recommended. I don’t get the notion of telling patients tough luck and not at least trying SCS. Yes SCS gets a bad wrap and is utilized in poorly selected patients a lot but in these patients who have nothing else to try I see little risk and they are happy to try it. Be diligent about expectations and only implant if strongly positive trial.

 

[DrMDAware]

I'm starting to do medial branch peripheral stim for my refractory axial lbp patients. Excited to start offering this option when nothing else works. Would definitely go this route over traditional stim for any axial pain syndromes

Nice. Which company are you using? I’ve heard about Reactiv8.

If my patients fail lumbar RFA I tend to doubt my technique.

 

[lobelsteve]

Nice. Which company are you using? I’ve heard about Reactiv8.

If my patients fail lumbar RFA I tend to doubt my technique.

I’ve never had a patient fail RFA.

But one of them came in yesterday (3 total just yesterday), and the first thing I do is go look at my placements. Great having big board monitors next to my desk. I think I was too lateral on TP on right side. But his pain was bilaterally so it couldn’t have been me. 😁

Even done perfectly with SIS technique and 80+% blocks, 5% failure rate. In an experimental population. So if I only get 75% of my RFA spine patients that 80+% relief at 10 months, it is a win.

So when I say I have never had a patient fail an RFA, it means I failed them.

 

[Ducttape]

I’ve never had a patient fail RFA.

But one of them came in yesterday (3 total just yesterday), and the first thing I do is go look at my placements. Great having big board monitors next to my desk. I think I was too lateral on TP on right side. But his pain was bilaterally so it couldn’t have been me. 😁

Even done perfectly with SIS technique and 80+% blocks, 5% failure rate. In an experimental population. So if I only get 75% of my RFA spine patients that 80+% relief at 10 months, it is a win.

So when I say I have never had a patient fail an RFA, it means I failed them.

why? you will have failure even with the perfect technique (i remember reading 13%, not 5)

This is how I and most of my personal colleagues view it as well. Postlaminectomy is often pain from epidural fibrosis compressing the nerve root. Not much different than degen spine with compression of the nerve root exiting the foramen. Agree that results aren’t very good for spinal stenosis but we offer SCS in patients with low back, buttock pain who have MRI showing nerve impingement and surgery not recommended. I don’t get the notion of telling patients tough luck and not at least trying SCS. Yes SCS gets a bad wrap and is utilized in poorly selected patients a lot but in these patients who have nothing else to try I see little risk and they are happy to try it. Be diligent about expectations and only implant if strongly positive trial.

its hard, but i tell people all the time that there is no injection to be done. false hope is not true hope, and the crash is devastating.

 

[MitchLevi]

Sometimes, you just can't get the needle where you want it. I tend to burn for an extra 30 sec in those cases.

 

[lobelsteve]

why? you will have failure even with the perfect technique (i remember reading 13%, not 5)

its hard, but i tell people all the time that there is no injection to be done. false hope is not true hope, and the crash is devastating.

Slow down, get a cup of coffee. Read the whole sarcastic ball of wax.

 

[Ducttape]

im trying to make you feel better about your abject failure rates....

 

[SC Tian]

Did any of you guys notice the failure of RFA after it is repeated for 3 to 4 times? I saw this trend at least in my practice.