Rule 4123-6-35 | Payment for spinal cord stimulator.
Reimbursement for a spinal cord stimulator for treatment of allowed conditions in a claim resulting from an allowed work related injury or occupational disease is limited to claims in which current best medical practices as implemented by this rule are followed.
This rule governs the bureau's reimbursement of a spinal cord stimulator to treat a work related injury or occupational disease. It is not meant to preclude, or substitute for, the treating physician's responsibility to exercise sound clinical judgment in light of current best medical practices when treating injured workers.
A provider's failure to comply with this rule may constitute endangerment to the health and safety of injured workers, and claims involving a spinal cord stimulator not in compliance with this rule may be subject to peer review by the bureau of workers' compensation stakeholders' health care quality assurance advisory committee (HCQAAC) pursuant to rule 4123-6-22 of the Administrative Code or other peer review committee established by the bureau.
Medical treatment reimbursement requests (on form C-9 or equivalent) for a spinal cord stimulator are not subject to dismissal by the MCO pursuant to paragraph (F)(7) of rule 4123-6-16.2 of the Administrative Code.
(A) Authorization for a spinal cord stimulator will be considered only in cases in which the following criteria are met:
(1) Allowed conditions. The injured worker has one or more of the following conditions allowed in their claim:
(a) Failed thoracic or lumbar spinal surgery.
(b) Complex regional pain syndrome.
(c) Non-operable peripheral vascular disease/limb ischemia.
(d) Neuropathic pain post-thoracic or post-lumbar surgery.
(e) Chronic thoracic or lumbar radiculopathy.
(f) Spinal cord injury dysesthesias.
(2) Conservative care. The injured worker has undergone at least sixty days of conservative care, which may include but is not limited to:
(a) Anti-inflammatory medication(s) treatment;
(b) Chiropractic or osteopathic treatment;
(c) Epidural steroid injection therapy;
(d) Pain management program participation;
(e) Physical medicine rehabilitation program participation; or
(f) Physical therapy.
(3) Surgeon evaluation. The injured worker has been personally evaluated by the operating surgeon and undergone a comprehensive evaluation, in which all of the following have been documented:
(a) Date of injury;
(b) Mechanism of injury;
(c) Past medical history, including:
(i) Prior surgeries;
(ii) List of current medical and psychological conditions;
(iii) List of current medications;
(iv) List of drug allergies.
(d) Physical examination;
(e) Pertinent neurological and vascular testing;
(f) Completion of a health behavioral assessment and, when appropriate, identified intervention services;
(g) Consideration of vocational rehabilitation services.
(4) Education. The injured worker and physician of record, treating physician, or operating surgeon have reviewed and signed the educational document, "What BWC Wants You to Know About Spinal Cord Stimulators," attached as an appendix to this rule.
(5) Spinal cord stimulator trial. Having met the criteria outlined in paragraphs (A)(1) to (A)(4) of this rule, and prior to implantation of a spinal cord stimulator, the injured worker has completed an approved seven-day spinal cord stimulator trial, with documented improvement in a majority of the following areas:
(a) Activities of daily living, documented through use of an evidence-based tool (e.g., "OSWESTRY Disability Index Questionnaire or Roland Morris Disability Questionnaire");
(b) Gait;
(c) Mood and affect;
(d) Pain level, documented through use of an evidence-based pain scale (e.g., visual analog scale) and a decrease of use of the morphine equivalent dosage of any pre-procedure opioid analgesic; and
(e) Sleep.
(B) BWC will not reimburse for a spinal cord stimulator:
(1) For the treatment of failed cervical spine surgery, neuropathic pain post-cervical surgery, or cervical radiculopathy;
(2) When the injured worker has an implanted pacemaker or defibrillator, metabolic or alcoholic neuropathy, or somatization disorder; or
(3) When any of the following documented conditions are uncontrolled or untreated:
(a) Substance use disorder;
(b) Psychosis; or
(c) Bipolar disorder.
Last updated September 1, 2022 at 8:29 AM
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