CurrentCareSourcePolicy N/A

Implantable Spinal Cord Stimulator (SCS)

Medical necessity and coverage criteria for trial and permanent implantation of implantable spinal cord stimulators for chronic neuropathic pain and chronic stable angina in CareSource Arkansas PASSE members.

Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization and submit trial documentation showing ≥50% pain reduction and ≥6 months of documented conservative therapy before requesting permanent implantation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-14 daystrial period duration required

>=50%trial pain reduction threshold

6 monthsmin conservative therapy

10,000 Hzhigh-frequency example

cervical placementinvestigational

Coverage Criteria

Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization and submit trial documentation showing ≥50% pain reduction and ≥6 months of documented conservative therapy before requesting permanent implantation.

SourceLink

On This Page

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Preliminary Trial (Neuropathic Pain)

Covered when ALL of the following are met for a preliminary trial (3-14 days) for chronic neuropathic pain:

Primary diagnoses: Member has one of the specified diagnoses: failed back surgery syndrome; complex regional pain syndrome/reflex sympathetic dystrophy; neuropathic pain that is moderate to severe (Visual Analog Scale ≥ 5); inoperable limb ischemia secondary to peripheral vascular disease.

based on list in policy

Evaluation and screening: Pain pathology is documented and surgical intervention is not indicated; member has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation; member has undergone psychological evaluation by a licensed mental health provider that reveals no evidence of inadequately controlled behavioral health problems (including substance use disorder, depression, psychosis) that would negatively impact SCS or contraindicate placement.

psychological evaluation required

Conservative therapy requirement: Failure of conservative therapy demonstrated by documentation in the medical record of at least 6 months of active conservative therapy within the past 12 months OR documentation of inability to complete active conservative therapy due to contraindication, increased pain, or intolerance; documentation of at least 6 months of inactive conservative therapy within the past 12 months is also referenced.6 months

see definitions for active/inactive conservative therapies (physical therapy, occupational therapy, physician‑supervised HEP, etc.)

Permanent Implantation

Covered when ALL of the following are met for permanent implantation (neuropathic pain or chronic stable angina):

Prerequisite from trial: Member met all preliminary trial criteria and achieved at least 50% reduction in pain during the trial period documented in the medical record.>=50%

trial success required

Chronic stable angina specific criteria: For chronic stable angina: member meets the relevant functional classification criteria, is not a candidate for revascularization, has failed optimal pharmacologic therapy (including long‑acting nitrates, beta‑blockers, calcium‑channel antagonists), and has undergone psychological evaluation without uncontrolled behavioral health problems.

angina-specific requirements listed in policy

Investigational / Not Medically Necessary

Not covered / investigational:

Investigational or not established indications: Cervical placement of SCS for any indication; treatment for members in a chronic vegetative or minimally conscious state; chronic cancer‑related pain; chronic pelvic pain (eg, chronic abdominal or visceral pain); irritable bowel syndrome; movement disorders (eg, Parkinson's disease); sleep disorders; sphincter of Oddi dysfunction; ventricular fibrillation/ventricular tachycardia; and other indications not listed as covered.

policy lists multiple investigational indications

High‑frequency replacement: Replacement of a functioning standard spinal cord stimulator with a high‑frequency spinal cord stimulator is considered not medically necessary; note that high‑frequency SCS is an equal alternative when used as primary therapy for medically necessary indications.

distinguishes replacement vs primary high-frequency use

In addition to the covered indications and prerequisites, the policy explicitly lists several scenarios as experimental, investigational, or otherwise not established. These include cervical placement of spinal cord stimulators for any indication, use of SCS in members who are in a chronic vegetative or minimally conscious state, and a range of other indications for which effectiveness has not been established such as chronic cancer‑related pain, chronic pelvic or visceral pain, irritable bowel syndrome, certain movement and neurodegenerative disorders (for example, Parkinson’s disease), and sleep disorders. These exclusions reflect the policy’s determination that SCS for these indications is investigational and not covered.

Providers should refer to the policy’s exclusions list when evaluating requests that fall outside the stated covered indications; requests for these indications are subject to denial as experimental or not medically necessary unless future evidence or policy updates change the coverage stance.

The policy states that replacement of a functioning standard spinal cord stimulator with a high‑frequency spinal cord stimulator is not considered medically necessary. At the same time, the policy clarifies that high‑frequency SCS is considered an acceptable alternative when used for medically necessary primary indications, but replacing a functioning device solely to switch to high‑frequency technology is not covered.

For replacement requests, the policy requires supporting device documentation (see provider requirements) and device interrogation reports to be submitted as part of the prior authorization; absence of this documentation may result in denial.

Coding and Thresholds

inv-06: Visual Analog Scale (VAS) threshold — >= 5 (moderate to severe neuropathic pain)

Visual Analog Scale (VAS) threshold>= 5 on 0-10 VAS (moderate to severe neuropathic pain)

Scale range0-10 numeric Visual Analog Scale

Clinical useUsed to define neuropathic pain severity for SCS eligibility

inv-07: Trial duration — 3-14 days

Trial duration (preliminary percutaneous trial)3-14 days

PurposeShort trial with temporary percutaneous leads and external generator to assess suitability for permanent SCS

SettingCan be performed in office under light sedation if appropriate sterility, equipment, training, and support personnel are available

inv-08: Trial success threshold — >= 50% pain reduction

Trial success threshold>= 50% reduction in pain during the trial period documented in the medical record

Documentation requirementPerformance and documentation of an effective trial is a prerequisite for permanent implantation

TransitionIf >=50% relief is achieved, temporary system may be transitioned to a permanent system

inv-09: Conservative therapy duration — >= 6 months active conservative therapy within prior 12 months

Minimum duration>= 6 months of active conservative therapy within the prior 12 months

Alternative documentationOr documented inability to complete active conservative therapy due to contraindication, increased pain, or intolerance

Inactive therapy documentationDocumentation of at least 6 months of inactive conservative therapy within the past 12 months is also referenced

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for both the SCS trial (preliminary trial, typically 3–14 days) and for permanent implantation. Submit a prior authorization request before performing the trial or permanent implant as applicable. Include clear indication of the planned procedure (trial vs permanent), target spine level (lumbar/thoracic), and proposed device type. Requests for replacement, removal, or upgrade also require prior authorization when coverage rules apply.

Trial and permanent implantation both require prior authorization
Specify whether request is for trial, permanent implant, replacement, or removal
Include proposed spine level and device type

Documentation Required

Required Supporting Documentation

The medical record must document required supporting information to adjudicate the request. For trials, document trial start/end dates, type of leads used, stimulation parameters, and objective trial outcome demonstrating at least 50% reduction in pain. For permanent implants or replacements, include operative reports, device model/serial numbers, and, for replacements, device interrogation and interpretation reports (see replacement documentation requirement). Include the multidisciplinary evaluation and psychological assessment results.

Trial documentation: dates, lead type/placement, external generator details, and ≥50% pain reduction documented (eg, VAS scores)
Permanent implant: operative report, device make/model/serial number
Replacements: device interrogation report with interpretation within 3 months of prior authorization request
Multidisciplinary team evaluation and psychological evaluation results

Documentation Required

Conservative Therapy Prerequisite

Members must have failed conservative therapy prior to consideration for SCS. The medical record must document at least 6 months of active conservative therapy within the past 12 months, or a documented inability to complete active conservative therapy due to contraindication, increased pain, or intolerance. Active and inactive conservative therapies must include dates, frequency, duration, and provider involved.

Document ≥6 months of active conservative therapy within the past 12 months (eg, PT, OT, physician‑supervised HEP)
Or document inability to complete active conservative therapy with reason (contraindication, increased pain, intolerance)
Record dates, frequency, duration, and TENS/medication use if applicable

Denial Risk

Contraindications That May Cause Denial

Presence of contraindications may lead to denial. Verify the member does not have any listed contraindications prior to authorization and document screening results in the chart.

Contraindications include coagulopathy, active infection or sepsis, major psychiatric disorders (including somatization), active/untreated substance use disorder
Presence of other implanted programmable devices (eg, pacemaker, defibrillator) that could interfere with SCS
Any documented contraindication should be clearly noted; unresolved contraindications may result in denial

Denial Risk

Investigational or Documentation-Based Denial Risks

Requests may be denied if the indication, placement, or documentation does not meet policy requirements or if the request involves investigational uses. Ensure documentation addresses all coverage criteria and includes required device and trial evidence.

Cervical placement of SCS for any indication is considered experimental/investigational and may be denied
Requests for indications not listed as covered (eg, chronic cancer‑related pain, chronic pelvic pain, IBS, Parkinson's disease, sleep disorders, certain gait disorders) are investigational
Replacement requests submitted without a device interrogation and interpretation report within 3 months may be denied
Requests lacking trial outcome documentation (≥50% pain reduction) or missing multidisciplinary/psychological evaluations may be denied

Definitions and Background

Spinal cord stimulation (SCS) delivers low‑voltage electrical current to the dorsal columns of the spinal cord to reduce neuropathic pain. It is most commonly used for neuropathic pain syndromes such as failed back surgery syndrome, complex regional pain syndrome, radiculopathies, phantom limb pain, and peripheral neuropathy. Management typically begins with a short, percutaneous trial period of 3–14 days to assess treatment response; if the trial demonstrates at least 50% pain reduction and other prerequisites are met, conversion to a permanent implant may be considered.

Appropriate patient selection requires multidisciplinary evaluation, documentation that surgical correction is not indicated, completion (or documented inability to complete) at least 6 months of active conservative therapy within the prior 12 months, and a psychological evaluation demonstrating no uncontrolled behavioral health conditions that would interfere with SCS outcomes. Permanent implantation should be performed in an ambulatory surgical center or hospital.

inv-16: Conservative Therapy — Definition of conservative therapy: multimodality plan including active and inactive conservative therapy.

DefinitionConservative Therapy: A multimodality plan of care including both active and inactive conservative therapy.

Active examplesPhysical therapy, occupational therapy, physician-supervised home exercise program (HEP)

Inactive examplesRest, ice/heat, medical devices, TENS, pharmacotherapy (use, frequency, duration, and start dates must be documented)

inv-17: HEP (Home Exercise Program) — Definition and requirements for a documented home exercise program.

HEP definitionHEP: A 6-week home exercise program requiring an exercise prescription/plan and follow-up documented in the medical record after completion

Acceptable alternativeDocumentation of inability to complete HEP for stated physical reasons (eg, increased pain, inability to perform exercises) is acceptable

Non-acceptable reasonsPatient inconvenience or unexplained noncompliance does not constitute inability to complete HEP

inv-18: High-Frequency SCS — Definition, example operating frequency (e.g., 10,000 Hz).

DefinitionHigh-Frequency Spinal Cord Stimulation: SCS that provides a higher frequency than traditional SCS

Example operating frequencyExample given: 10,000 Hz (versus traditional 40-60 Hz)

Policy stanceHigh-frequency SCS is considered an equal and effective alternative to standard SCS for medically necessary indications; replacement of a functioning standard SCS with high-frequency SCS is not considered medically necessary

inv-19: VAS — Visual Analog Scale definition and threshold (0-10 scale; >=5 considered moderate to severe).

VAS definitionVisual Analog Scale (VAS): Numerical pain scale 0-10

Threshold for eligibility>= 5 on 0-10 VAS is considered moderate to severe neuropathic pain and used in criteria

Clinical applicationUsed to quantify pain severity for determining SCS candidacy

OpenPayer

Implantable Spinal Cord Stimulator (SCS)

Coverage Criteria

Coding and Thresholds

Provider Actions & Documentation Requirements

Definitions and Background

Conservative Treatment Requirements

Frequency Limits & Device Requirements

Imaging and Procedural Setting Requirements

Not Covered / Exclusions