CurrentCareSourcePolicy N/A

Implantable Spinal Cord Stimulator (SCS) - Arkansas PASSE

This policy governs medical necessity, coverage criteria, contraindications, exclusions, and replacement/maintenance rules for spinal cord stimulation (SCS) including trial and permanent implantation for CareSource members in Arkansas PASSE.

Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS) - Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionObtain and document a 3–14 day trial with ≥50% pain reduction prior to permanent SCS implantation and secure prior authorization with required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%trial pain reduction required

3-14drecommended trial duration

6 moactive conservative therapy required

10,000 Hzreferenced high-frequency

Arkansasjurisdiction

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Preliminary SCS Trial (inv-01)

CareSource considers a preliminary SCS trial (3–14 days) medically necessary when ALL of the following are met:

ALL of the following

The member has one of the following diagnoses: failed back surgery syndrome; complex regional pain syndrome (reflex sympathetic dystrophy); neuropathic pain that is moderate to severe (>= 5 on a 10-point Visual Analog Scale); or inoperable limb ischemia secondary to peripheral vascular disease.
Pain pathology is documented in the medical record.
Surgical intervention is not indicated.
The member has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation.
The member has undergone a psychological evaluation by a licensed mental health provider (eg, face-to-face assessment with or without questionnaires/testing) that reveals no evidence of an inadequately controlled behavioral health problem that would negatively impact SCS success, including substance use disorders, uncontrolled depression, or psychosis.
Failure of conservative therapy, evidenced by ALL of the following: documentation of at least 6 months of active conservative therapy within the past 12 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance; and documentation of at least 6 months of inactive conservative therapy within the past 12 months.

Permanent SCS Implantation (inv-02)

CareSource considers a permanently placed SCS for the treatment of chronic pain medically necessary when ALL of the following are met:

ALL of the following

All preliminary trial criteria have been met (see Preliminary SCS Trial).
At least a 50% reduction in pain was achieved during the trial period and is documented in the medical record.

SCS for Chronic Stable Angina (inv-03)

CareSource considers a preliminary trial (3–14 days) for implantable SCS for chronic stable angina pectoris medically necessary when ALL of the following are met:

ALL of the following

Member's angina is Class III or Class IV on the New York Heart Association and Canadian Cardiovascular Society Functional Classifications.
Member has failed to obtain satisfactory improvement of symptoms with optimal pharmacological therapy, including long-acting nitrates, beta-adrenergic blockers, and calcium-channel antagonists.
Member is not a candidate for revascularization procedures (coronary artery bypass graft or percutaneous transluminal coronary angioplasty).
Member has undergone a psychological evaluation by a licensed mental health provider (eg, face-to-face assessment with or without questionnaires/testing) that reveals no evidence of an inadequately controlled behavioral health problem that would negatively impact SCS success, including substance use disorders, uncontrolled depression, or psychosis.

CERVICAL PLACEMENT: Cervical placement of an SCS for any indication is considered experimental and investigational and is not covered by CareSource.

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Replacement of a functioning standard SCS with a high-frequency SCS is not considered medically necessary.

Key Coding Thresholds and Values

inv-06: Trial pain reduction threshold — >= 50% pain reduction documented during trial

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

Trial duration3–14 days (preliminary percutaneous trial with temporary leads and external generator)

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

inv-07: Active conservative therapy duration — >= 6 months within past 12 months

Active conservative therapy minimum duration>= 6 months of active conservative therapy within the past 12 months

Inactive conservative therapy requirement>= 6 months of inactive conservative therapy within the past 12 months

Exception for inability to complete active therapyDocumented medical inability (eg, increased pain, physical inability, contraindication) may substitute for active therapy

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for all requests for permanent implantation and for replacement generators when the existing device is no longer repairable and is out of warranty. Prior authorization must include documentation of device interrogation reports with interpretation obtained within 3 months of the request for generator replacement.

Permanent implantation and replacement generators require PA
Device interrogation report with interpretation must be submitted for generator replacement (within 3 months)

Prior Authorization

Trial Required Before Permanent Implantation

A preliminary SCS trial of a temporary percutaneous lead(s) with an external generator for approximately 3–14 days must be performed and documented prior to approval for permanent implantation. The trial must demonstrate effectiveness, defined as at least 50% reduction in pain during the trial period. The trial may be performed in an appropriately equipped office setting or ambulatory/surgical setting when sterility and support personnel are available.

Trial duration: typically 3–14 days
Effectiveness threshold: ≥ 50% pain reduction documented

Documentation Required

Required Documentation for Prior Authorization

Submit comprehensive documentation with the prior authorization request to support medical necessity. Required documentation includes: the member’s diagnosis and documented pain pathology; multidisciplinary evaluation and surgical non‑intervention rationale; results of prior conservative therapies (medications, injections, physical therapy, etc.); psychological evaluation addressing major psychiatric disorders and substance use; and documentation of the trial results if applicable.

Diagnosis and pain pathology
Multidisciplinary evaluation and statement that surgical intervention is not indicated
Prior conservative therapies tried and response
Psychological evaluation and substance use assessment
Documentation of trial (duration and ≥50% pain relief)

Denial Risk

Denial Triggers: Contraindications and Exclusions

Requests will be denied for members with any contraindication or exclusion. Contraindications include active infection or sepsis, coagulopathy, major psychiatric disorders (including somatization), active and untreated substance abuse disorder, and presence of other implanted programmable devices that could interact (eg, pacemaker, defibrillator). Exclusions include indications considered experimental/investigational (eg, cervical SCS placement, intra-operative monitoring use, chronic cancer‑related pain, chronic pelvic pain, and other non‑neuropathic chronic pain indications not specified as covered).

Active infection or sepsis
Coagulopathy
Major psychiatric disorders (including somatization)
Active, untreated substance abuse disorder
Other implanted programmable devices that may interfere (eg, pacemaker/ICD)
Cervical SCS and other indications listed as experimental/investigational

Definitions and Key Terms

inv-13: Conservative Therapy — multimodality plan including active therapies (PT, OT, supervised HEP, injections, etc.)

DefinitionA multimodality plan of care including both active therapies (eg, physical therapy, occupational therapy, physician‑supervised HEP) and inactive therapies (eg, rest, heat/ice, TENS, pharmacotherapy)

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

Inactive therapies examplesRest, ice/heat, medical devices, TENS use, pharmacotherapy

DocumentationUse, frequency, duration, and start dates of therapies must be documented in the medical record to be considered part of conservative therapy

inv-14: HEP (Home Exercise Program) — 6-week program requiring prescription/plan and follow-up or valid inability documentation

Program length6‑week program requiring an exercise prescription/plan

Follow-up requirementFollow-up documented in the medical record after completion

ExceptionDocumentation of inability to complete HEP for valid medical reasons (eg, increased pain, inability to physically perform exercises) is acceptable; patient inconvenience or unexplained noncompliance is not sufficient

inv-15: High Frequency Spinal Cord Stimulation — example cited: 10,000 Hz

Example operating frequency10,000 Hz (high-frequency SCS)

Comparison to traditional SCSHigher than traditional SCS which operates in the 40–60 Hz range

inv-16: Visual Analog Scale (VAS) — 0–10 numerical pain intensity scale

Scale range0–10 numerical scale

PurposeUsed to measure pain intensity from mild to severe (Visual Analog Scale, VAS)

Background on Spinal Cord Stimulation

Spinal cord stimulation (SCS) delivers low‑voltage electrical current to the dorsal columns to reduce neuropathic pain and is best suited for neuropathic conditions such as failed back surgery syndrome, complex regional pain syndrome, radiculopathies, phantom limb pain, and peripheral neuropathy. SCS is generally ineffective for nociceptive or central deafferentation pain.

Implantation is staged: a short percutaneous preliminary trial (typically 3–14 days) using temporary leads and an external generator is performed first. If the trial produces adequate pain relief (documented ≥50% reduction in pain), the member may proceed to permanent lead and pulse generator implantation.

Appropriate candidate selection requires documentation of pain pathology, multidisciplinary evaluation, and psychological assessment demonstrating no inadequately controlled behavioral health condition that would contraindicate implantation. Conservative therapy (both active and inactive components) must be attempted and documented prior to trial unless valid medical inability to complete active therapy is recorded.

High‑frequency SCS devices operate at substantially higher stimulation frequencies (policy gives 10,000 Hz as an example) compared with traditional 40–60 Hz devices; however, device selection and replacement are governed by the policy’s coverage and replacement rules.

Not Covered / Exclusions

Not covered under this policy: cervical SCS placement for any indication and replacement of a functioning standard SCS with a high‑frequency SCS. Cervical placement is listed among procedures considered experimental and investigational. Although high‑frequency stimulators are acknowledged as an alternative for medically necessary indications, changing a functioning standard device to a high‑frequency device is specifically stated as not medically necessary.

Additionally, the policy designates multiple other indications as investigational and not covered because effectiveness has not been established; examples include chronic vegetative or minimally conscious state, chronic cancer‑related pain, chronic pelvic pain, gait disorders, irritable bowel syndrome, Parkinson’s disease, sleep disorders, sphincter of Oddi dysfunction, types of chronic non‑malignant non‑neuropathic pain not listed elsewhere, and ventricular arrhythmias.

Prior authorization remains required for permanent implantation and for generator/battery replacement requests; for replacement requests device interrogation and interpretation reports obtained within a minimum of 3 months must be submitted with the prior authorization.

OpenPayer

Implantable Spinal Cord Stimulator (SCS) - Arkansas PASSE

Coverage Criteria for Spinal Cord Stimulation

Key Coding Thresholds and Values

Conservative Treatment and Therapy Requirements

Provider Requirements, Prior Authorization, and Documentation

Definitions and Key Terms

Replacement and Frequency Limits

Background on Spinal Cord Stimulation

Not Covered / Exclusions