Prior authorization required for SCS/DRG trial

Prior authorization is required before approval for a short-term SCS or DRG trial; providers must demonstrate that trial criteria are met, including conservative therapy duration, indication, surgical candidacy, and behavioral health attestation.

• Prior authorization required for short-term trial requests
• Submission must demonstrate that trial criteria (per policy) are met

Authorization must document trial criteria and response

Authorization requests must document that the specific trial criteria were met and must include trial response for permanent implant requests (e.g., documented ≥50% pain relief during the short-term trial or the beneficial clinical response specified by the indication).

• Document indication-specific diagnostic criteria and required attestations
• For permanent implantation, include documented ≥50% pain relief during the short-term trial when required

Replacement of existing stimulator requires malfunction/revision documentation

Replacement of an existing dorsal column or DRG stimulator requires documentation that the device/generator is malfunctioning and not repairable/warranty-covered, or that electrode revision is required; only in those circumstances is replacement considered medically necessary.

• Show device/generator malfunction and non-repairable status (not under warranty), or
• Show revision of electrode percutaneous array(s) or plate/paddle(s) is required

Code listing & prior authorization notice — check plan rules

CPT codes listed in the policy include 63650, 63655, and 63685; inclusion of these codes does not imply they require prior authorization—providers must check the member's health plan for prior authorization rules and payment terms.

• 63650 — percutaneous implantation of neurostimulator electrode array, epidural
• 63655 — laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
• 63685 — insertion or replacement of spinal neurostimulator pulse generator or receiver
• Inclusion of a code in the table is not a guarantee of management or payment; refer to the applicable health plan

No prior-authorization codes listed in bibliography

No additional prior‑authorization codes or requirements are listed in the bibliography reference pages; providers must rely on the policy text and the member's plan for authorization rules.

• Reference/bibliography pages do not list prior authorization codes or requirements

Trial and conservative therapy prerequisites before implantation

A short-term SCS trial (generally >48 hours or as specified per indication) is required prior to permanent implantation, and providers must document failure of physician‑supervised conservative medical management for at least six consecutive months before trial authorization.

• Short-term trial duration usually greater than 48 hours (PDPN trial specified as at least 5 days)
• Document failure of ≥6 consecutive months of physician‑supervised conservative therapy prior to trial

Conservative therapy and medication trials required before trial

Before initiating a short-term trial, document failure of physician‑supervised conservative care (commonly at least six consecutive months) and, for PDPN, trial/intolerance of at least two medication classes and HbA1c/opioid limits where applicable.

• PDPN: ineffective relief or intolerance to ≥2 of anticonvulsants, TCAs, SNRIs, or opioids
• PDPN: HbA1c <10% within 3 months prior to trial and if on opioids, ≤100 MME/day

Repeat short-term trial after failure is not allowed

If the initial short-term dorsal column SCS trial fails, a repeat short-term trial is considered not medically necessary and should not be pursued as a step toward permanent implantation.

• Repeat short-term trial after a failed initial trial is not medically necessary

No additional step therapy requirements in bibliography

No step therapy requirements beyond the stated conservative therapy and trial prerequisites are specified in the bibliography pages.

• No additional step therapy rules found in bibliography chunks

Required documentation for SCS trial

Required documentation for an SCS trial includes evidence of at least six consecutive months of physician‑supervised conservative therapy, documentation that surgery is not indicated or was declined, and a behavioral health attestation (face‑to‑face or virtual).

• Document ≥6 months of physician‑supervised conservative management (pharmacotherapy, PT, CBT, activity/lifestyle modification)
• Document surgical candidacy status (not indicated or patient declines surgery)
• Provide behavioral health attestation (face-to-face or virtual assessment; questionnaires/testing optional)

Required clinical attestations and supporting tests

Include required clinical attestations and supporting tests: behavioral health provider attestation that no uncontrolled mental/behavioral conditions exist; for PDPN include HbA1c within 3 months and medication trial/opioid documentation; for CLI include vascular surgeon attestation; for angina include treating cardiologist attestation.

• Behavioral health attestation (face-to-face or virtual assessment)
• PDPN: HbA1c <10% within 3 months and documentation of trials of ≥2 medication classes; opioid MME if applicable
• CLI: vascular surgeon attestation that patient is not a candidate for vascular reconstruction
• Angina: treating cardiologist attestation confirming CAD and unsuitability for revascularization

Replacement documentation required for replacement to be medically necessary

For replacement requests, submit documentation that the existing stimulator and/or battery/generator is malfunctioning, cannot be repaired, and is no longer under warranty, or that electrode revision is required to justify replacement.

• Evidence of device/generator malfunction and non-repairable status (out of warranty), or
• Evidence that revision of electrode arrays or plate/paddle(s) is required

Plan-specific authorization and payment guidance — check member's plan

Providers must refer to the applicable health plan for management details and the member's Certificate of Coverage or Evidence of Coverage for terms and conditions governing payment; prior authorization of a listed code is not a guarantee of payment.

• Prior authorization rules and payment details determined by the member's health plan
• Certificate of Coverage/Evidence of Coverage governs payment terms

No documentation requirements in bibliography pages

No documentation requirements are stated in the bibliography reference pages; they are citations only. Use the policy sections for actual documentation requirements.

• Bibliography pages contain references only and do not specify documentation requirements

Denial triggers for SCS trial

Denial triggers include failure to document at least six consecutive months of physician‑supervised conservative medical management, omission of the required behavioral health attestation, or performing a trial shorter than the policy‑specified duration (>48 hours or indication‑specific duration).

• Missing ≥6 months conservative therapy documentation may trigger denial
• Absence of behavioral health attestation may trigger denial
• Trial shorter than required duration (>48 hours or as specified) may trigger denial

Missing required attestations or criteria may cause denial

Requests may be denied if required attestations (behavioral health, specialty attestations) or indication‑specific criteria are not met — examples include PDPN HbA1c <10% within 3 months, opioid ≤100 MME/day if applicable, CRPS diagnostic criteria, CLI pressure thresholds, or required documented trial pain relief for permanent implantation.

• PDPN: HbA1c <10% within 3 months and medication trial documentation required
• PDPN: opioid use ≤100 MME/day if applicable
• CRPS: diagnostic sign/symptom criteria and ≥6 months conservative therapy
• CLI: resting ankle pressure <40 mmHg and toe pressure <30 mmHg and vascular/advanced imaging attestations
• Permanent implant: documented ≥50% pain relief during trial where required

SCS placement without meeting criteria is not medically necessary

Placement of a non‑high‑frequency or high‑frequency dorsal column SCS without meeting the Definitions, General Guidelines, and Indications is considered not medically necessary and may be denied.

• Ensure all Definitions, General Guidelines, and Indications criteria are met before placement

Initial DRG placement and inappropriate replacements are not medically necessary

Initial placement of a DRG stimulator for any indication and replacement of a dorsal column SCS with a DRG stimulator are considered not medically necessary and may be denied; initial DRG placement is not covered under this policy.

• Initial DRG stimulator placement is considered not medically necessary for all indications
• Replacement of a dorsal column SCS with a DRG stimulator is considered not medically necessary

Coding inclusion does not guarantee authorization or payment

Inclusion of procedure codes in the policy table does not imply those codes require prior authorization or guarantee payment; check the member's plan for prior authorization and payment rules.

• Inclusion of a code in the table is not a guarantee of payment
• Refer to the applicable health plan for prior authorization and payment details

No authorization/denial criteria in bibliography

No authorization or denial criteria are present in the bibliography pages; rely on the policy's Indications, General Guidelines, and Definitions sections for authorization requirements.

• Bibliography does not contain authorization/denial criteria

Use fluoroscopic guidance for DRG lead placement

DRG stimulation leads must be placed percutaneously into the epidural space under fluoroscopic guidance; ensure fluoroscopic imaging is used for lead placement.

Include angiographic, CT, or MRI imaging for CLI trial

For CLI trial criteria, advanced imaging (angiographic, CT, or MRI) demonstrating multilevel disease with absence of named vessel flow into the foot is required; include the specified imaging in documentation.