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CGS PAR 369: OPD Spinal Neurostimulator Prior Auth

Hospital outpatient departments in Kentucky and Ohio need CGS prior authorization before implanting a spinal neurostimulator for an Original Medicare patient, under CMS's OPD program. This request asks whether records support chronic intractable pain, multidisciplinary screening, earlier treatments and a psychological evaluation. The decision's UTN must appear on the hospital's claim, and related claims can deny if the implant is non-affirmed.

Who completes it

Hospital outpatient department staff complete the request with the OPD's PTAN, NPI and type of bill, the beneficiary, and the attending physician's name, NPI, fax and address, answering the clinical questions from the physician's documentation. CMS also lets a physician or practitioner submit on the hospital's behalf.

Submitting and payment

How to submit it
Submit before the service through myCGS (preferred), esMD, or by fax or mail using the Kentucky or Ohio line on the form. CGS decides in 7 calendar days, or 2 business days for justified expedited requests.
Who pays
The hospital reports the UTN on its Part A outpatient claim (type of bill 13X): an affirmed UTN means the claim will likely pay if other requirements are met, while a service billed with no UTN automatically denies.

Good to know

  • Q4 asks for documentation of a psychological evaluation; without it, the implant may not be considered medically necessary.
  • Q3 lists earlier treatments the records should show: pharmacological therapy, surgery, physical therapy and psychological therapy.
  • Q1 asks whether the records support chronic intractable pain, and Q2 whether they show careful screening, evaluation and diagnosis by a multidisciplinary team.
  • Originated March 26, 2021, and revised August 22, 2023. Decisions and UTNs stay valid for 120 days for one date of service.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization OPD: Implanted Spinal Neurostimulators

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does a spinal cord stimulator need a psychological evaluation for CGS prior authorization?

The CGS form asks in Q4 whether the medical records include documentation of a psychological evaluation, and notes that a No answer means the procedure may not be considered medically necessary. Send the evaluation with the request along with the multidisciplinary screening records.

Which records support a CGS spinal neurostimulator request?

Records showing chronic intractable pain; careful screening, evaluation and diagnosis by a multidisciplinary team; prior pharmacological, surgical, physical or psychological treatment; and a psychological evaluation. Page 3 of PAR 369 gives space for the condition, associated symptoms and rationale for the procedure.

Who submits the neurostimulator request?

The hospital outpatient department, which enters its PTAN, NPI and type of bill. CMS also allows the implanting physician or another practitioner to submit on the hospital's behalf, as long as the decision and UTN are passed to the hospital for its type of bill 13X claim.