VIA ELECTRONIC TRANSMISSION
D. Scott Kreiner, MD
North American Spine Society
7075 Veterans Blvd.
Burr Ridge, IL 60527
SUBJECT: NASS Draft Model Coverage Policy on Spinal Cord Stimulator
Dear Dr. Kreiner:
On behalf of the American Association of Neurological Surgeons (AANS), and the Congress of
Neurological Surgeons (CNS), we appreciate the opportunity to comment on the North American Spine
Society’s (NASS) draft model coverage policy recommendation for spinal cord stimulation (SCS).
We are generally in agreement with the policy but have the following concerns. Below we have noted the
NASS statement from the policy, followed by our AANS/CNS comments in bold text.
NASS Coverage Recommendations:
The draft policy states that a SCS trial is indicated when ALL the following criteria are met.
- The patient has moderate-to-severe axial spine and/or extremity pain attributable to the spine or
neuropathic in nature, causing some degree of functional deficit.
The criteria include axial and extremity pain but patients can have neuropathic visceral pain as well, for
which SCS is an option. We would recommend the wording below to modify the criteria to add
neuropathic visceral pain to align with the soon to be published evidence-based guidelines from the
Congress of Neurological Surgeons and the North American Neuromodulation Society (NANS):
a. The patient has moderate-to-severe axial and/or extremity pain attributable to the spine or
neuropathic in nature, e.g. CRPS types I and II, neuropathic visceral pain, peripheral vascular disease,
diabetic neuropathy, causing some degree of functional deficit. - The pain has been present for at least 6 months and has persisted despite the failure of multiple
conservative nonsurgical treatments, such as medications, physical therapy, psychological therapy, or
other modalities, or has persisted despite previous surgical intervention. We agree with this point. - No active substance abuse issues. We agree with this point.
- Psychological evaluation has ruled out known risk factors such as significant cognitive dysfunction, active psychosis, untreated or poorly controlled addiction, and untreated or poorly controlled psychological disorders. We agree with this point.
- There is no identifiable cause for the patient’s pain that can be reasonably addressed with surgery, or
the patient is deemed not a candidate for major surgical intervention due to medical comorbidities or
elevated surgical risk. We have several concerns with this wording. We believe that this implies that all
patients under consideration for a trial of SCS would need to be seen by a spine surgeon and that spinal
surgery, if offered, would take precedence over a trial of SCS, regardless of patient preferences. SCS
has been shown in randomized trials to be superior to repeat spinal surgery when there is no overt
instability or progressive neurologic deficit attributable to neural compression.1 Moreover, while a
patient may be a candidate for a spinal surgery, they should be free to choose to instead undergo a trial
of SCS rather than have the trial denied because the larger procedure is an option.
Read full letter here.
