ModifiedUnitedHealthcarePolicy CS061NE.AB

Implanted Electrical Stimulator for the Spinal Cord (for Nebraska Only)

Nebraska-specific UnitedHealthcare medical policy governing coverage and medical necessity criteria for implanted spinal cord stimulators (SCS) and dorsal root ganglion (DRG) stimulation, including indications considered proven or unproven and coding references; applies to members and providers in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyImplanted Electrical Stimulator for the Spinal Cord (for Nebraska Only)

Policy CodePolicy CS061NE.AB

Change TypeRevisions to coverage rationale, DRG language, and documentation requirements

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument in the medical record the indication, prior conservative therapies, trial stimulation status, and supporting test results to meet prior authorization and medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

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

Replaced language about DRG stimulation being proven and medically necessary 'when performed according to FDA labeled indications, contraindications, warnings, and precautions' (removed redundant 'performed according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions').

Added specific medical records documentation requirements stating the patient's record must contain documentation that fully supports medical necessity and be made available upon request.

Removed reference links to two Nebraska-only medical policies: Bariatric Surgery and Gastrointestinal Motility Disorders, Diagnosis and Treatment.

Related Billing Codes

HCPCS-L8686-IMPLANTABLE-NEUROSTIMULATOR-PULSE-GENERATOR-SINGLE-ARRAY-NON-RECHARGEABLE

HCPCS L8686: Implantable Neurostimulator Pulse Generator, Single Array

HCPCS-L8680-IMPLANTABLE-NEUROSTIMULATOR-ELECTRODE

HCPCS L8680: Implantable Neurostimulator Electrode

HCPCS-L8687-IMPLANTABLE-NEUROSTIMULATOR-RECHARGEABLE-DUAL-ARRAY

HCPCS L8687: Implantable Rechargeable Neurostimulator Pulse Generator, Dual Array

HCPCS-L8688-IMPLANTABLE-NEUROSTIMULATOR-PULSE-GENERATOR-DUAL-ARRAY-NON-RECHARGEABLE

HCPCS L8688: Implantable Neurostimulator Pulse Generator, Dual Array, Non-Rechargeable

HCPCS-L8679-IMPLANTABLE-NEUROSTIMULATOR-PULSE-GENERATOR

HCPCS L8679: Implantable Neurostimulator Pulse Generator

HCPCS-L8695-EXTERNAL-RECHARGING-SYSTEM-IMPLANTABLE-NEUROSTIMULATOR-REPLACEMENT

HCPCS L8695: External Recharging System for Implantable Neurostimulator, Replacement Only

HCPCS-L8682-IMPLANTABLE-NEUROSTIMULATOR-RADIOFREQUENCY-RECEIVER

HCPCS L8682: Implantable Neurostimulator Radiofrequency Receiver

CPT-63650-EPIDURAL-ELECTRODE-IMPLANTATION-FOR-PAIN-SPASM

CPT 63650: Epidural Electrode Implantation for Pain and Spasm

CPT-63685-SPINAL-NEUROSTIMULATOR-PULSE-GENERATOR-INSERTION

CPT 63685: Insertion or Replacement of Spinal Neurostimulator Pulse Generator, Surgical

HCPCS-L8685-IMPLANTABLE-RECHARGEABLE-NEUROSTIMULATOR-PULSE-GENERATOR

HCPCS L8685: Implantable Rechargeable Neurostimulator Pulse Generator

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Coverage Criteria for SCS and DRG Stimulation

Covered Indications (SCS)

Covered when ALL of the following are met and performed per FDA labeling and InterQual SCS insertion criteria

Covered Indications for SCS: SCS is proven and medically necessary for: Complex regional pain syndrome (CRPS); Painful diabetic neuropathy; Failed back surgery syndrome.

See InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion for detailed clinical criteria and patient selection.

Unproven / Not Medically Necessary (SCS)

Not medically necessary due to insufficient evidence

Unproven/Not Medically Necessary: Chronic intractable back pain without prior spine surgery; Refractory angina pectoris.

Policy states these uses are unproven and not medically necessary due to insufficient evidence.

Covered Indications (DRG)

Covered when ALL of the following are met and performed per FDA labeling and InterQual criteria

Covered Indication for DRG: DRG stimulation is proven and medically necessary for Complex regional pain syndrome (CRPS I, CRPS II) in certain circumstances.

Refer to InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion for medical necessity clinical criteria.

Unproven / Not Medically Necessary (DRG)

Not medically necessary for other uses

DRG Unproven Uses: DRG stimulation is unproven and not medically necessary for all other conditions besides CRPS due to insufficient evidence of efficacy.

Evidence-informed coverage considerations

Evidence-supported considerations for coverage decisions

Evidence and guideline-informed conditions: Consider SCS for refractory angina as adjunctive therapy when patients are not candidates for revascularization, based on meta-analyses showing reduced angina frequency and nitroglycerin use; consider DRG stimulation for select neuropathic pain syndromes (CRPS, causalgia, focal pelvic/groin pain, peripheral nerve injury) where randomized trials or cohort data show substantial rates of ≥50% pain relief but recognize evidence limitations and need for further long-term studies.see citations

Document conservative therapy attempts and patient selection; perform trial stimulation per ASRAPM except when anginal pain is present.

Coverage-related clinical criteria and guidance

Key coverage-related points and clinical guidance extracted from referenced guidelines and policy changes:

Trial stimulation: An SCS trial should be performed before definitive implantation except when there is anginal pain.

Recommendation per ASRAPM and FDA advisories; document trial results when performed.

DRG stimulation coverage: DRG stimulation is proven and medically necessary for treating complex regional pain syndrome (CRPS I, CRPS II) in certain circumstances when performed according to FDA labeled indications, contraindications, warnings, and precautions.

Policy language clarified in revision; see documentation requirements in policy history.

HF10 (Senza) guidance: HF10 therapy (Senza) may be considered for chronic neuropathic back or leg pain ≥50 mm VAS at least six months after back surgery despite conventional medical management and after a successful stimulation trial as part of a multidisciplinary assessment.VAS >= 50 mm; >=6 months post-surgery

Based on NICE recommendations and considered in coverage deliberations.

This policy states that implanted electrical spinal cord stimulators (SCS) are unproven and not medically necessary for certain uses when evidence is insufficient. Specifically, SCS is considered not medically necessary for chronic intractable back pain without prior spine surgery and for refractory angina pectoris. For indications that may be appropriate, the policy requires that implantation and claims meet FDA labeling and the InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion clinical criteria; refer to InterQual for detailed patient selection and medical necessity elements prior to authorizing an implant.

The policy highlights device-related safety concerns observed in the literature, including high rates of lead-related complications (fracture, migration), pocket-site pain, and infections. Published DRG series report lead fracture and migration with resulting revisions and, in some cases, retained lead fragments and permanent nerve injury. Systematic reviews and pooled analyses identify infection risks that are higher after implant than during trial stimulation, with pooled implant infection rates reported in the literature. These device- and procedure-related risks are factors to consider during candidate selection and when counseling patients prior to trial or permanent implantation.

The VA/DoD 2022 Clinical Practice Guideline is cited in the policy and explicitly recommends against use of spinal cord stimulation for patients with low back pain. This guideline finding is incorporated as a referenced evidence source when considering SCS for nonspecific low back pain and informs the policy’s determination that such use is unsupported.

The policy contains explicit noncoverage and not medically necessary statements for SCS when used to treat chronic intractable back pain without prior spine surgery. It also cites systematic review evidence showing no benefit of SCS at six months for low back pain compared with placebo, and the NASS guideline’s review which found no adequate studies addressing electrical stimulation for low back pain. Taken together, these sources support the policy’s classification of SCS for isolated low back pain without prior surgery as not medically necessary.

The policy summarizes evidence syntheses and trials relevant to neuromodulation. A Cochrane-style systematic review identified multiple trials of SCS for low back pain but reported no benefit at six months for function, pain, or quality of life versus placebo in the one study measuring outcomes at six months. Meta-analyses and pooled analyses of DRG and SCS cohorts report responder rates (commonly defined as ≥ 50% pain reduction) in many implanted cohorts, but also note limitations including short follow-up, small sample sizes, and industry sponsorship. These evidence limitations are cited as the basis for cautious coverage determinations and for restricting certain indications.

The North American Spine Society (NASS) systematic review referenced in the policy concluded that there were no studies adequate to address electrical stimulation for low back pain. This absence of high-quality evidence is noted in the policy as a reason to withhold coverage for isolated low back pain indications lacking supportive trial data.

Applicable Codes and Coding Notes

Covered CPT Codes (listed in policy Applicable Codes)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.

Applicable HCPCS/L codesHCPCS

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, nonrechargeable, includes extension.
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension.
L8688	Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension.
L8695	External recharging system for battery (external) for use with implantable neurostimulator, replacement only.

FDA product codes referencedmixed

LGW	FDA product code referenced for PMA-approved spinal cord stimulation systems
GZB	FDA product code referenced for PMA-approved spinal cord stimulation systems
GZF	FDA product code referenced for 510(k) spinal cord stimulation systems
PMP	FDA product code referenced for dorsal root ganglion stimulation devices

Responder rate definition (inv-16)

Responder rate threshold≥ 50% reduction in pain on the Numerical Rating Scale (NRS) or Visual Analog Scale (VAS) as used in cited trials

Measurement instrumentsNumerical Rating Scale (NRS) and Visual Analog Scale (VAS) used across randomized trials cited in the policy

Timepoints referencedResponder rates reported at primary endpoints in trials (commonly 3–6 months and longer-term follow-up up to 24 months in some studies)

Use in trial/crossover analysesResponder definition (≥50% pain reduction) applied to both immediate-treatment and crossover participants in several RCTs

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for spinal cord stimulator (SCS) implantation in Nebraska under policy CS061NE.AB. Coverage decisions reference the InterQual® CP: Procedures, Spinal Cord Stimulator (SCS) Insertion criteria; requests must demonstrate the member meets those clinical criteria and FDA labeled indications, contraindications, warnings, and precautions.

Payer: UnitedHealthcare
Policy Number: CS061NE.AB
Effective Date: 2026-02-01

Prior Authorization

Document Indication, Conservative Therapy, and Trial Status

Submit documentation of the indication for SCS, prior conservative therapies attempted and optimized, and the status and results of any trial stimulation. For indications such as complex regional pain syndrome (CRPS), painful diabetic neuropathy, failed back surgery syndrome, or other InterQual-covered diagnoses, include dates, duration, and response to prior treatments (pharmacologic, interventional, physical therapy, behavioral therapies, and device-based therapies where applicable).

Required Conservative Therapies Before Implantation

Document prior conservative therapies and trial results when applicable

Document prior conservative therapies and trial results: Document prior conservative therapies attempted (e.g., optimization of medical management, physical therapy, interventional procedures where appropriate) and the results of any SCS/DRG trial when performed.

ASRAPM and InterQual referenced; prior authorization should include documentation of prior therapies and trial status.

Failure of conventional medical management after prior back surgery required before considering HF10 per NICE guidance

HF10 candidate requirements: Patient has residual chronic neuropathic back or leg pain at least 50 mm on a 0–100 mm VAS and symptoms persist at least six months after back surgery despite conventional medical management.>= 6 months; VAS >= 50 mm

Replacement and Frequency Rules

Replacement battery/generator coverage conditions (inv-37)

Replacement battery/generator coverage conditionAllowed when the individual's existing battery/generator is malfunctioning, cannot be repaired, and is no longer under warranty

ScopeApplies to replacement of previously implanted electrical stimulator battery/generator

Documentation implicationMedical record should support device malfunction and warranty status per policy documentation requirements

Imaging and Assessment Requirements

Billing Rule

Applicable procedure and device codes; refer to InterQual for imaging/procedural details

Use the listed CPT and HCPCS/L codes when requesting authorization or billing for SCS/DRG procedures and devices; specific procedural imaging requirements are not detailed here—refer to InterQual and procedural guidance as needed.

Common CPTs: 63650, 63655, 63685, 63688.
Common HCPCS/L codes: L8679, L8680, L8682, L8685–L8688, L8695.

Documentation Required

Use validated instruments for psychosocial screening and document results

Screen patients with objective, validated instruments for psychosocial factors as part of patient selection; include screening results in the record.

Background and Scope

This policy governs use of implantable neuromodulation therapies, including spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation, for members in Nebraska. SCS and DRG are implantable devices intended to modulate neural pathways to reduce chronic neuropathic pain. The policy identifies specific conditions considered proven and medically necessary (for example, complex regional pain syndrome, painful diabetic neuropathy, and failed back surgery syndrome for SCS; CRPS for DRG) when performed per FDA labeling and InterQual criteria, and it identifies indications considered unproven or not medically necessary due to insufficient evidence. The scope includes coverage stance, coding references, trial-stimulation and documentation expectations, and replacement battery/generator guidance.

Key Definitions and Success Metrics

Conditions (SCS/DRG) considered proven (inv-30)

Proven SCS indicationsComplex regional pain syndrome (CRPS); Painful diabetic neuropathy; Failed back surgery syndrome

Proven DRG indicationComplex regional pain syndrome (CRPS I, CRPS II) in certain circumstances

Performance requirementWhen performed according to FDA labeled indications, contraindications, warnings, and precautions and InterQual clinical criteria

Refractory Angina Pectoris (RAP) — definition and context (inv-31)

DefinitionRefractory angina pectoris (RAP): chronic angina not amenable to revascularization or percutaneous intervention and managed as an adjunctive therapy in select patients

Evidence contextMultiple systematic reviews/meta-analyses (e.g., Pan et al., Imran et al.) found SCS reduces angina frequency, nitroglycerin use, and may increase exercise time in RAP

Services Not Covered

Not covered by this policy are uses of implanted spinal cord stimulators for which evidence is insufficient. Examples explicitly listed include chronic intractable back pain without prior spine surgery and refractory angina pectoris. The policy also states that dorsal root ganglion stimulation is unproven and not medically necessary for all indications other than those specifically recognized (CRPS I/II). Systematic reviews cited in the policy (including a Cochrane-style review and the NASS guideline review) found no convincing benefit of SCS for low back pain at six months or identified no adequate studies, supporting noncoverage for nonspecific low back pain indications.