scs new requirement

[PinchandBurn]

For humana patients..
it's not just sufficient they have persistent pain after spine surgery.

one has to send the patient to a SURGEON for even a scs trial.

So what about SPine surgeons that do SCS trials. Do they have to get a surgical opinion from someone? Or can they just do a trial and we cant?

This reminds me of the kypho scenario for a spine surgeon. How are these Spine Surgery lobbying groups getting this stuff into these new LCDs???? It's ridiculous.

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[BobBarker]

There is a NCD for SCS that supersedes anything Humana wants to put in the way. Just pull up the NCD and ask them where that requirement is, then if they persist ask them if they will state “I, Bob Doe, MD, do willingly deny authorization of SCS trial for a reason not required in the NCD.” They will fold and authorize it.

 

[PinchandBurn]

You are correct.

However the NCD is broad. You don't need to have fbss or crps...just pain for more than 6months.

Ncd is just mcr.

Problem is humana and the other commercial payors do not have to follow the NCD.

For their advantage plans they are supposed to, but will deny. Then it's a toss up .

It's just a lot of Bs to stop access.

 

[BobBarker]

I think Humana has or will exit the commercial market. Medicare Advantage only for them going forward.

 

[clubdeac]

You guys see SCS getting called investigational by CMS and essentially killing it any time soon or no?

 

[pmrmd]

I think Humana has or will exit the commercial market. Medicare Advantage only for them going forward.

Humana will be MA only next year. Fact.

 

[mdo1738]

You guys see SCS getting called investigational by CMS and essentially killing it any time soon or no?

That would be the most CMS move ever, to take something that has been around and approved for 60 years but suddenly send it back to the realm of investigational. But no, I don’t see that happening. While we are pretty divided and don’t do a good job advocating for our specialty as a whole, I think any actual threat to SCS would unite us all in a way that losing SI joint RFA did not.

 

[PinchandBurn]

That would be the most CMS move ever, to take something that has been around and approved for 60 years but suddenly send it back to the realm of investigational. But no, I don’t see that happening. While we are pretty divided and don’t do a good job advocating for our specialty as a whole, I think any actual threat to SCS would unite us all in a way that losing SI joint RFA did not.

The device companies wouldn't let that happen...
Some how did they allow the surgeon mandate. Maybe they are trying to reach surgeons so they can do these as well. More market share for the companies.

Reverse of what's done for spinal fusion/simplicity

 

[bedrock]

My state WC is trying to avoid paying for both SCS and Intracept by saying both procedures (including SCS trials) should only be performed by a surgeon.

Truly laughable considering how bad most surgeons would be at both procedures.

Unfortunately I have to tell WC patients who need SCS/Intracept to do it under their private insurance.

 

[Ducttape]

to be devils advocate - what WC carrier would want to pay for procedures that are geared towards chronic pain management in a population that is most likely not working and has no intention of returning to work?



the problem is that their involvement in these patient's care means that the patient's private insurances will indubitably deny coverage....

 

[lobelsteve]

You guys see SCS getting called investigational by CMS and essentially killing it any time soon or no?

1967

 

[MitchLevi]

SCS does NOT work in Work Comp patients, and I do not recommend it.

I've done one implant (failed, classic CRPS), and recently agreed to do a trial that failed on a patient with literally textbook distal left leg neuropathic pain. Popliteal anesthesia on a foot/ankle surgery with residual nerve pain in the calf, ankle and foot.

There is a reason they will always fight you on this.

They have one study from years ago that shows a wild failure rate in Work Comp "CRPS." Unfortunately, it's true.

Also, SCS has an extremely high failure rate in general.

 

[lobelsteve]

SCS does NOT work in Work Comp patients, and I do not recommend it.

I've done one implant (failed, classic CRPS), and recently agreed to do a trial that failed on a patient with literally textbook distal left leg neuropathic pain. Popliteal anesthesia on a foot/ankle surgery with residual nerve pain in the calf, ankle and foot.

There is a reason they will always fight you on this.

They have one study from years ago that shows a wild failure rate in Work Comp "CRPS." Unfortunately, it's true.

Also, SCS has an extremely high failure rate in general.

Research typically excludes WC patients due to COI. Patients want money and not want to return to work.

 

[Ducttape]

SCS implants does NOT work in Work Comp patients, and I do not recommend it.

I've done one implant (failed, classic CRPS), and recently agreed to do a trial that failed on a patient with literally textbook distal left leg neuropathic pain. Popliteal anesthesia on a foot/ankle surgery with residual nerve pain in the calf, ankle and foot.

There is a reason they will always fight you on this.

They have one study from years ago that shows a wild failure rate in Work Comp "CRPS." Unfortunately, it's true.

Also, SCS has an extremely high failure rate in general.

fixed it for you.

the trials work great. the implants dont.

 

[Greenbayslacker]

Popliteal anesthesia on a foot/ankle surgery with residual nerve pain in the calf, ankle and foot.

Planning on DRG?

 

[MitchLevi]

Planning on DRG?

No way.

 

[Agast]

I’m surprised you still have private pay Humana, our region is Medicare advantage only

 

[swamprat]

fixed it for you.

the trials work great. the implants dont.

You know I sometimes notice this in implant patients too. I try to figure out why - leads not exactly the same? Tachyphylaxis from therapy after a couple weeks? I do find that patients that like the traditional paresthesias and do well on trial have no issues with implant and reprogramming.

 

[Agast]

I mentally subtract 20% from each trial on how much improvement to expect with their implant. So anyone who is “50% better” will not love their implant long term. 70% improvement will say long term the implant was worth it but did not give them the relief they were expecting. The rare 90-100% are the happiest long term.

 

[MitchLevi]

This is all condemnation about a therapy that pays well but doesn’t work. I too have a few home runs but all in all it is a pretty low performing intervention. Virtually all my implants are failed back, vast majority are leg and low back pain. Very high failure rate despite good lead placement.

If industry didn’t pay for every conference we attend, and if SCS didn’t pay well no one would do it.

 

[callmeanesthesia]

This is all condemnation about a therapy that pays well but doesn’t work. I too have a few home runs but all in all it is a pretty low performing intervention. Virtually all my implants are failed back, vast majority are leg and low back pain. Very high failure rate despite good lead placement.

If industry didn’t pay for every conference we attend, and if SCS didn’t pay well no one would do it.

By definition it’s a last ditch effort on patients who have failed PT, meds, injections, and surgery. Considering that I find it as effective as you could hope it would be and then some.

 

[Greenbayslacker]

No way.

How well does dorsal column stim cover foot/ankle pain compared to DRG...

 

[PinchandBurn]

You know I sometimes notice this in implant patients too. I try to figure out why - leads not exactly the same? Tachyphylaxis from therapy after a couple weeks? I do find that patients that like the traditional paresthesias and do well on trial have no issues with implant and reprogramming.

I 100% agree.

All these fancy waveforms exist. In my practice those that have done the best are with tonic.

The reps hate putting tonic.

Also reps want me to put scs leads to t7 or t6. 90% of the time I get great coverage from t8 to t9.. sometimes t10...sometimes old school thinking just works...

 

[MitchLevi]

How well does dorsal column stim cover foot/ankle pain compared to DRG...

I quit doing DRG stim bc it is a tremendous pain in the butt and underperformed in my hands.

Admittedly, I didn’t do a ton of DRG cases but this is also work comp, so when the leads migrate I’ll be having to revise them and spend work comp’s money to do it.

No reason to think DRG is any better than dorsal column in this case (or any case), despite what industry sponsored data says.

 

[gdub25]

By definition it’s a last ditch effort on patients who have failed PT, meds, injections, and surgery. Considering that I find it as effective as you could hope it would be and then some.

Agree with this. What else are you going to offer these stim patients. They are desperate and have tried everything else. It's a relatively safe thing to try and most people are very happy to have been given the option. As long as everyone's expectations have been set appropriately then I still see it as a positive option to try.

 

[Rocuronium18]

Canadian here.

Our center is one of the largest in Canada with regards to spinal cord stimulator implants, performing about 75 implants per year (new implants and replacements). Every time I come to US conferences, I hear a lot about “patient selection“, but don’t really hear much more about what is done to ensure patients are appropriately selected. All of our patients undergo pain psychiatry assessment, MRI to rule out structural pathology/ensure access OK, online pain education and supervised physical therapy prior to undergoing trial. We then use multiple patient reported outcome measures to assess the efficacy of the trial, and only implant if there is a global 50% improvement across multiple domains.

Our explant rate is 3% over the last 5 years. Our main implant indications are predominantly failed back surgery syndrome, and CRPS.

I think it’s definitely a valuable therapy, but appropriate patient selection is so so crucial. FYI, we don’t get paid extra for doing SCS implants over other procedures.

 

[CopaceticOne]

Our center is one of the largest in Canada with regards to spinal cord stimulator implants, performing about 75 implants per year (new implants and replacements).

That doesn't sounds like a very large number. Off the top of my head I can say we do >150 every year with just one surgeon at one of our hospitals (3 new implants per day in each of their OR blocks, not sure if they have some weeks with more than one OR block).

Possible you already do patient selection without realizing it?

Note: not a pain doc

 

[clubdeac]

That doesn't sounds like a very large number. Off the top of my head I can say we do >150 every year with just one surgeon at one of our hospitals (3 new implants per day in each of their OR blocks, not sure if they have some weeks with more than one OR block).

Possible you already do patient selection without realizing it?

Note: not a pain doc

I think you just reinforced his point