CurrentCareSourcePolicy N/A

Implantable Spinal Cord Stimulator (SCS) — Arkansas PASSE

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

Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS) — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateApr 1, 2026

Last ReviewFeb 28, 2024

Next Review DateN/A

Key ActionA 3–14 day trial with documentation of at least 50% pain reduction is required before approval of permanent SCS.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-14 daystrial period

>=50%trial pain reduction

6 monthsconservative therapy

10,000 Hzhigh-frequency SCS

Arkansas (PASSE)

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CurrentCareSourcePolicy N/A

Implantable Spinal Cord Stimulator (SCS) — Arkansas PASSE

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Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS) — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateApr 1, 2026

Last ReviewFeb 28, 2024

Next Review DateN/A

Key ActionA 3–14 day trial with documentation of at least 50% pain reduction is required before approval of permanent SCS.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-14 daystrial period

>=50%trial pain reduction

6 monthsconservative therapy

10,000 Hzhigh-frequency SCS

Arkansas (PASSE)

Coverage Criteria for Spinal Cord Stimulation

Initial trial for chronic pain

Preliminary trial (3-14 days) for chronic pain is considered medically necessary when ALL of the following are met:

Eligible diagnoses: Member has one of: failed back surgery syndrome; complex regional pain syndrome/reflex sympathetic dystrophy; moderate to severe neuropathic pain (Visual Analog Scale >= 5); inoperable limb ischemia secondary to peripheral vascular disease

chunk 4

Pain documentation: Pain pathology is documented in the medical record

chunk 4

Surgical candidacy: Surgical intervention is not indicated

chunk 4

Multidisciplinary evaluation: Member has undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to implantation

chunk 5

Psychological evaluation: Member has undergone a psychological evaluation by a licensed mental health provider that reveals no evidence of uncontrolled behavioral health problems (including substance use disorder, depression, or psychosis) that would negatively impact SCS success

chunk 5

Conservative therapy failure: Failure of conservative therapy, evidenced by BOTH: (a) documentation of at least 6 months of active conservative therapy within the past 12 months OR documented inability to complete active therapy due to contraindication, increased pain, or intolerance; AND (b) documentation of at least 6 months of inactive conservative therapy within the past 12 months6 months

chunk 5 and definitions in chunk 3

Permanent implantation for chronic pain

Permanent SCS is medically necessary when ALL of the following are met:

Prior criteria met: Member met all preliminary trial criteria (see initial trial for chronic pain)

refer to initial trial criteria

Trial success: At least 50% reduction in pain was achieved during the trial and is documented in the medical record>=50%

chunk 5

Chronic stable angina pectoris

Trial and permanent implantation for chronic stable angina pectoris are considered medically necessary when ALL the following are met:

Severity: Member's angina is Class III or Class IV on the New York Heart Association and Canadian Cardiovascular Society functional classificationsClass III or IV

chunk 7

Medication failure: Member failed to obtain satisfactory improvement with optimal pharmacologic treatment (including long-acting nitrates, beta-adrenergic blockers, and calcium-channel antagonists)

chunk 4

Not candidate for revascularization: Member is not a candidate for coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention)

chunk 4

High-frequency SCS

High-frequency SCS stance:

Equivalence: High-frequency spinal cord stimulators (operating at ~10,000 Hz) are considered an equal and effective alternative to standard SCS for the medically necessary indications listed

chunks 10 and 3

Not necessary to replace functioning device: Replacement of a functioning standard spinal cord stimulator with a high-frequency spinal cord stimulator is not considered medically necessary

chunk 10

Removal/replacement

Replacement and removal:

Generator replacement: Replacement of a lumbar or thoracic SCS generator/battery is medically necessary when the existing stimulator and/or battery/generator are no longer under warranty and cannot be repaired; lead/electrode replacement is generally not required at time of generator replacement

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Replacement documentation: Device interrogation reports with interpretation must be acquired and submitted within a minimum of 3 months of the prior authorization request for replacement3 months

chunk 10

Removal of an SCS is considered medically necessary even when initial implant would not have been indicated

chunk 10

CareSource considers the following uses of spinal cord stimulation (SCS) to be experimental or investigational and not covered because effectiveness has not been established: intra‑operative motor evoked potential and somatosensory evoked potential use, cervical placement of an SCS for any indication, and all other indications not listed as medically necessary. Examples of excluded indications include chronic vegetative or minimally conscious state, chronic cancer‑related pain, chronic pelvic/visceral pain, gait disorders (including spinocerebellar ataxia), irritable bowel syndrome, Parkinson’s disease, and sleep disorders, as well as additional listed conditions (see exclusions list).

CareSource considers high‑frequency spinal cord stimulators (HF‑SCS) an equal and effective alternative to standard SCS for medically necessary indications; however, replacement of a functioning standard SCS with a high‑frequency SCS is not considered medically necessary and will not be covered.

Provider Requirements and Documentation

Prior Authorization

Trial and documentation requirement

A preliminary trial (3–14 days) and documentation of at least a 50% reduction in pain during the trial are required prior to approval of a permanent spinal cord stimulator (SCS) implant. Prior authorization for a permanently placed SCS will only be considered when trial criteria and all medical necessity requirements are met and the 50% pain reduction is documented in the medical record.

Trial duration: 3–14 days
Documented pain reduction: >= 50% during trial
Documentation must be in the medical record and submitted with PA

Denial Risk

Contraindications trigger denial

Presence of any contraindication listed below is a basis for denial of SCS placement. Confirm the member does not have any contraindicating condition prior to proceeding with trial or implantation.

Conservative Treatment History Requirements

Documented conservative therapy history required before trial

Documented conservative therapy history required before trial:

Duration requirement: At least 6 months of active conservative therapy within the past 12 months OR documented inability to complete active therapy due to contraindication, increased pain, or intolerance; AND at least 6 months of inactive conservative therapy within the past 12 months>=6 months

Definitions of active and inactive conservative therapies and HEP requirements in chunk 3; criteria in chunk 5

Active therapy examples: Active conservative therapies include physical therapy, occupational therapy, or a physician-supervised home exercise program (HEP) with documented follow-up

chunk 3

HEP standard: HEP defined as a 6-week program requiring an exercise prescription and documented follow-up; documentation of inability to complete HEP must note physical reason (eg, increased pain)

Definitions and Key Terms

SCS trial — Short trial with temporary percutaneous electrodes and external generator

DefinitionShort trial with temporary percutaneous electrodes and external generator to assess suitability for permanent implant

Typical duration3-14 days

Trial setupOne or two leads placed via an epidural needle with temporary external generator

Success thresholdAt least 50% pain relief during trial required to proceed to permanent implant

Conservative Therapy — Multimodality plan including active and inactive therapies

DefinitionMultimodality plan of care including both active and inactive conservative therapy

Frequency Limits and Timing Requirements

SCS trial — Trial limited to 3-14 days

Allowed trial duration3-14 days per trial episode

Placement during trialTemporary percutaneous implantation of neurostimulator electrode(s) with external generator

Trial settingCan be performed under light sedation in an office setting if appropriate sterility, equipment, and personnel are available

Generator/battery replacement prior authorization — Device interrogation within 3 months required

PA documentation requirementDevice interrogation reports with interpretation must be submitted with the prior authorization request for replacement

Recency requirementDevice interrogation must be acquired within a minimum of 3 months of the prior authorization request

Surgical and Imaging Requirements

Note

Perform permanent implantation in ASC or hospital with appropriate lumbar/thoracic lead placement

Permanent SCS implantation must be performed as surgery in an ambulatory surgical center or hospital, with appropriate lead placement (lumbar or thoracic) determined by the condition and pain pattern.

Surgery for implantation of a permanent neurostimulator must be performed in an ambulatory surgical center or hospital.
Appropriate system and lead placement (lumbar or thoracic dorsal column SCS) depend on the underlying condition and pain pattern.

Background

Spinal cord stimulation (SCS) delivers a low‑voltage electrical current to the dorsal columns of the spinal cord to modulate pain signaling and is best suited for neuropathic pain syndromes. Typical indications include failed back surgery syndrome, complex regional pain syndrome, radiculopathies, phantom limb pain, peripheral neuropathy, and select ischemic limb pain conditions. Standard practice uses a two‑stage approach: a short percutaneous trial (usually 3–14 days) with externalized leads to assess efficacy followed by permanent implantation if the trial demonstrates adequate pain relief.

Prior to trial and implantation, members should have a documented history of conservative therapies and multidisciplinary evaluation, and undergo psychological screening to identify any behavioral health contraindications that could affect SCS outcomes.

Not Covered / Exclusions

Not covered items specifically include cervical placement of SCS for any indication and the routine use of intra‑operative motor and somatosensory evoked potentials as part of SCS procedures. Additionally, CareSource excludes indications not identified as medically necessary in the policy (see exclusions list) and will deny coverage for SCS uses outside the specified indications.

Policy Summary

PayerCareSource

PolicyImplantable Spinal Cord Stimulator (SCS) — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateApr 1, 2026

Last ReviewFeb 28, 2024

Next Review DateN/A

Key ActionA 3–14 day trial with documentation of at least 50% pain reduction is required before approval of permanent SCS.

SourceLink

On This Page

Psych evaluation and trial success:

Member has undergone psychological evaluation without contraindicating behavioral health issues AND achieved at least 50% reduction in pain during the trial documented in the medical record

Active infection or sepsis
Coagulopathy
Major psychiatric disorders, including somatization
Active and untreated substance use disorder
Other implanted programmable devices (eg, pacemaker, defibrillator) that may interfere with SCS function

Documentation Required

Required documentation for prior authorization and replacements

Prior authorization requests for replacement of an SCS component (eg, generator/battery) must include recent device interrogation with an interpreted report. Device interrogation reports with interpretation must be acquired within a minimum timeframe and submitted with the PA request.

Device interrogation with interpretation must be acquired within 3 months of the prior authorization request
Interrogation report and interpretation must be included in the medical record submitted for PA
Replacement is covered when the existing device is no longer under warranty and cannot be repaired; lead/electrode replacement not generally required at generator replacement

Active therapies (examples)

Physical therapy, occupational therapy, supervised home exercise program (HEP)

HEP requirement6-week program with exercise prescription and documented follow-up or documented inability to complete

Inactive therapies (examples)Rest, ice/heat, medical devices, TENS, pharmacotherapy

High Frequency SCS — Definition

DefinitionForm of spinal cord stimulation operating at a higher frequency than traditional SCS

Operating frequency10,000 Hz

Policy stanceConsidered an equal and effective alternative to standard SCS for medically necessary indications

Replacement indicationGenerator/battery replacement covered when device is no longer under warranty and cannot be repaired

Lead replacement noteLead and electrode replacement are not generally required at time of generator replacement