CurrentUnitedHealthcarePolicy CS061NM.C

Implanted Electrical Stimulator for the Spinal Cord (for New Mexico Only)

UnitedHealthcare New Mexico medical policy defining coverage rationale, medical necessity stance, applicable codes, documentation expectations, and evidence summary for implanted spinal cord stimulators (SCS) and dorsal root ganglion (DRG) stimulation including replacement generators/batteries.

Policy Summary

PayerUnitedHealthcare

PolicyImplanted Electrical Stimulator for the Spinal Cord (for New Mexico Only)

Policy CodePolicy CS061NM.C

Change TypeRevisions to indications and DRG language; evidence/reference updates

Effective DateFeb 1, 2026

Next Review Date

Key ActionPatient medical record must contain relevant medical history, physical exam, and diagnostic test/procedure results that fully support medical necessity and be made available upon request.

SourceLink

POLICY UPDATE CHANGES

Revised list of proven and medically necessary conditions; replaced 'painful lower limb diabetic neuropathy' with 'painful diabetic neuropathy'.

Reworded DRG stimulation coverage statement to indicate DRG stimulation is proven and medically necessary for treating complex regional pain syndrome (CRPS I, CPRS II) when performed according to FDA labeled indications, contraindications, warnings, and precautions (removal of word 'refractory').

Removed reference link to the Medical Policy titled Bariatric Surgery (for New Mexico Only) and Gastrointestinal Motility Disorders, Diagnosis and Treatment (for New Mexico Only) from the Summary of Changes dated 02/01/2026.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.

Added language that medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage.

Added explicit list of required medical record documentation elements (relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures).

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS061NM.B.

Revision history repeatedly notes updates to Clinical Evidence and References; no specific clinical policy statement changes are provided in this fragment.

3Indications listed as medically necessary (SCS)

2Indications listed as not medically necessary/unproven

1DRG indication listed as medically necessary

RevisionsKey Policy Edits

ManyReferences Updated

Coverage Summary

This UnitedHealthcare New Mexico policy (effective February 1, 2026) addresses coverage for implanted electrical spinal cord stimulators (SCS) and dorsal root ganglion (DRG) stimulation. It defines the policy scope, subject, and coverage stance: SCS and DRG stimulation are proven and medically necessary for specific indications when performed according to FDA labeled indications, contraindications, warnings, and precautions, and are not medically necessary / unproven for other listed conditions. The policy also specifies coverage conditions for replacement batteries/generators.

Covered SCS indications listed as medically necessary in certain circumstances include complex regional pain syndrome (CRPS), painful diabetic neuropathy, and failed back surgery syndrome. DRG stimulation is listed as proven and medically necessary for complex regional pain syndrome (CRPS I, CRPS II) when performed per FDA labeling. High-level exclusions include SCS for chronic intractable back pain without prior spine surgery and refractory angina pectoris, and DRG stimulation is considered not medically necessary for indications other than the listed CRPS indication. For specific clinical thresholds, trial requirements, and medical necessity determinations, the policy references the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion.

Coverage is subject to federal, state, or contractual requirements and applicable laws; medical records documentation (including relevant history, physical exam, and diagnostic test results) may be required to assess whether clinical criteria are met but does not guarantee coverage.

Key Policy Facts

Policy numberCS061NM.C

SubjectImplanted Electrical Spinal Cord and Dorsal Root Ganglion Stimulators

PayerUnitedHealthcare New Mexico

Effective dateFebruary 1, 2026

StatusCURRENT

Scope summaryDefines coverage rationale, medical necessity stance, applicable codes, documentation expectations, and evidence summary for SCS and DRG stimulation including replacement generators/batteries in New Mexico.

Has material changeRevised proven/medically necessary conditions and DRG language; replaced 'painful lower limb diabetic neuropathy' with 'painful diabetic neuropathy'

Medical-Necessity Criteria

Medically Necessary - Implanted Electrical Spinal Cord Stimulators

Implanted electrical spinal cord stimulators are proven and medically necessary for treating the following conditions in certain circumstances when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions:

ANY of the following

Complex regional pain syndrome (CRPS)
Painful diabetic neuropathy
Failed back surgery syndrome

Related requirement

Procedures must be performed according to FDA labeled indications, contraindications, warnings, and precautions

Provider Actions & Authorization

Prior Authorization

Reference to InterQual criteria for coverage decision

Medical necessity clinical coverage criteria require referring to the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion to determine if the member meets coverage criteria, including trial requirements and specific clinical thresholds that govern approval decisions.

Documentation Required

Medical record support for medical necessity

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Required elements include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. These records may be requested and must be made available upon request to support a coverage determination.

Coding

Relevant CPT Codes (reference only)CPT

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, requiring pocket creation and connection between electrode array and pulse generator or receiver.
63688	Revision or removal of implanted spinal neurostimulator pulse generator or receiver, with detachable connection to electrode array.

Relevant HCPCS/L-codes (reference only)HCPCS

L8679	Implantable neurostimulator, pulse generator, any type.
L8680	Implantable neurostimulator electrode, each.
L8682	Implantable neurostimulator radiofrequency receiver.
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension.
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension.
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension.
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension.
L8695	External recharging system for battery (external) for use with implantable neurostimulator, replacement only.

Background & Evidence Summary

This New Mexico–specific policy summarizes the clinical and evidentiary rationale for coverage decisions for SCS and DRG stimulation. The policy cites systematic reviews, randomized controlled trials, and health-technology assessments — including reports and assessments from Hayes, ECRI, multiple systematic reviews and RCTs (for example, the ACCURATE trial and trials of 10-kHz SCS and BurstDR), and pooled analyses — to inform coverage positions.

Evidence summaries in the policy note favorable randomized trial outcomes for certain SCS systems (e.g., DISTINCT, Kapural 2022) showing substantial responder rates versus conventional medical management, and DRG evidence (including the ACCURATE trial and multiple reviews) reporting higher treatment success for CRPS compared with traditional SCS but overall limited or low-quality evidence for many DRG indications. The policy therefore ties coverage to the published evidence and directs reviewers to use InterQual criteria to determine specific medical necessity thresholds and trial/implant requirements.

Evidence Summary

DISTINCT responder rateSCS arm 85.3% vs CMM 6.2% (≥50% NRS reduction) at primary endpoint

Kapural 2022 (10-kHz SCS RCT)At 3 months 80.9% responder with 10-kHz SCS vs 1.3% with CMM; sustained at 6 months

Hayes DRG assessmentLimited body of evidence; overall very low quality for DRG—supports use in lower-limb CRPS but calls for more studies

Revision History

02/01/2026non-materialLatest

materialLatest

Revised list of proven and medically necessary conditions; replaced 'painful lower limb diabetic neuropathy' with 'painful diabetic neuropathy'.

Policy Summary

PayerUnitedHealthcare

PolicyImplanted Electrical Stimulator for the Spinal Cord (for New Mexico Only)

Policy CodePolicy CS061NM.C

Change TypeRevisions to indications and DRG language; evidence/reference updates

Effective DateFeb 1, 2026

Next Review Date

Key ActionPatient medical record must contain relevant medical history, physical exam, and diagnostic test/procedure results that fully support medical necessity and be made available upon request.

SourceLink

On This Page

For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion

InterQual criteria determine specific clinical thresholds and trial requirements

Not Medically Necessary / Unproven - Implanted Electrical Spinal Cord Stimulators

Implanted electrical spinal cord stimulators are unproven and not medically necessary for the following conditions due to insufficient evidence of efficacy:

ANY of the following

Chronic intractable back pain without prior spine surgery
Refractory angina pectoris

Medically Necessary - Dorsal Root Ganglion (DRG) Stimulation

DRG stimulation is proven and medically necessary for treating the following when performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions:

ALL of the following

Complex regional pain syndrome (CRPS I, CRPS II)
Procedures must be performed according to FDA labeled indications, contraindications, warnings, and precautions
For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion

Not Medically Necessary / Unproven - Dorsal Root Ganglion (DRG) Stimulation

DRG stimulation is unproven and not medically necessary for all other conditions due to insufficient evidence of efficacy.

Any indication not listed as medically necessary above

Replacement Battery/Generator Coverage

Coverage note regarding replacement battery/generator

Coverage of a replacement battery/generator for a previously implanted electrical stimulator is appropriate when the individual's existing battery/generator is malfunctioning, cannot be repaired, and is no longer under warranty

Documentation Required

Medical records documentation required for review

Medical records documentation that may be required for review must fully support medical necessity, be legible, maintained in the patient's medical record, and made available upon request. Documentation should include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Billing Rule

Replacement device coverage condition

Coverage of a replacement battery/generator for a previously implanted electrical stimulator is appropriate only when the existing device is malfunctioning, cannot be repaired, and is no longer under warranty.

L8679
L8685
L8686
L8687
L8688
L8695

Documentation Required

Reference federal/state/contractual coverage

Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws, which may require coverage for a specific service and may govern in the event of conflict with this policy.

Documentation Required

Use clinical judgment and external tools

UnitedHealthcare medical policies are intended to be used with the independent professional medical judgment of a qualified provider. UnitedHealthcare may use third-party tools (for example, InterQual) to assist in administering benefits; these tools supplement but do not replace clinician judgment.

ACCURATE trial (Deer et al. 2017)DRG: 81.2% treatment success vs SCS: 55.7% at 3 months; device-related and serious AEs similar

Huygen pooled analysis (2020)Weighted mean pain score 3.4 and 63% reported ≥50% pain relief at 12 months among 217 with permanent implant

Vuka et al. 2019 systematic reviewSuggests potential benefit of EFS DRG in highly selected patients; evidence limited by small studies and low quality

NICE recommendations (2019, 2020)Support HF10 therapy (Senza) for certain patients after failed back surgery; recommend trial stimulation and registry data submission

VA/DoD 2022 guidelineRecommended against SCS for low back pain

ECRI and other evidence summariesECRI and systematic reviews report effectiveness for some SCS technologies but note study limitations and bias concerns

DISTINCT and other RCTs overallMultiple RCTs demonstrate high responder rates for selected high-frequency SCS in nonsurgical refractory back pain

ACCURATE subanalysesSome DRG subjects achieved paresthesia-free analgesia; responder and safety data variable

Infection/complication dataPooled DRG infection rates: trial ~1.03%, implant ~4.80%, overall ~2.82%; complications include lead issues and pocket pain

Reworded DRG stimulation coverage statement to indicate DRG stimulation is proven and medically necessary for treating complex regional pain syndrome (CRPS I, CRPS II) when performed according to FDA labeled indications, contraindications, warnings, and precautions (removal of word 'refractory').

non-materialLatest

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.

non-materialLatest

Added language that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.

non-materialLatest

Added explicit list of required medical record documentation elements (relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures).

revisedLatest

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS061NM.B.

clarifiedLatest

Archived previous policy version CS061NM.B; updated Clinical Evidence and References sections to reflect the most current information; revision history repeatedly notes updates to Clinical Evidence and References.