CurrentUnitedHealthcarePolicy CS061KS.02

Implanted Electrical Stimulator Spinal Cord Ks Cs

UnitedHealthcare medical policy CS061KS.02 (Kansas only) defines coverage rationale, medical necessity determination references (InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion), applicable CPT and HCPCS codes, and statements on proven vs unproven indications for implanted spinal cord stimulators and dorsal root ganglion (DRG) stimulation. This part (1 of 2) provides coverage rationale, documentation expectations, applicable codes, and extensive evidence summary.

Policy Summary

PayerUnitedHealthcare

PolicyImplanted Electrical Stimulator Spinal Cord Ks Cs

Policy CodePolicy CS061KS.02

Change TypeRevisions to covered indicationsDRG wording clarified

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity (history, exam, diagnostics) and meet InterQual SCS insertion criteria for coverage consideration.

SourceLink

POLICY UPDATE CHANGES

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

Replaced language regarding DRG stimulation for refractory CRPS with wording that DRG stimulation is proven and medically necessary for treating CRPS I and II when performed according to FDA-labeled indications, contraindications, warnings, and precautions.

Added detailed Medical Records Documentation language outlining documentation expectations to assess medical necessity.

Updated Clinical Evidence and References sections to reflect current information; archived previous policy version CS061KS.01.

Policy title was changed from 'Implanted Electrical Stimulator for Spinal Cord (for Kansas Only) Coverage Rationale Implanted Electrical Spinal Cord Stimulators' to current title.

Updated reference link to reflect the current policy title for Gastrointestinal Disorders Diagnostic Procedures (for Kansas Only).

3Proven covered indications (SCS)

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Coverage Summary

This Kansas-only UnitedHealthcare medical policy (CS061KS.02) covers implanted spinal cord stimulators (SCS) and dorsal root ganglion (DRG) stimulation for selected chronic pain conditions. The policy uses InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion to determine medical necessity and specifies that certain indications are considered proven and medically necessary when performed according to FDA-labeled indications, contraindications, warnings, and precautions, while other uses are described as unproven and not medically necessary.

Quick coverage counts and key facts

Proven SCS indications (count)3

DRG proven indication (count)1

Referenced HCPCS device codes (count)8

Notable randomized comparative trialACCURATE (DRG vs SCS) — 1 RCT, 152 subjects

ACCURATE key outcome at 3 monthsDRG 81.2% ≥50% pain relief vs SCS 55.7%

Medical-Necessity Criteria

Covered when ALL of the following are met (Implanted electrical spinal cord stimulators)

Covered when ALL of the following are met (Implanted electrical spinal cord stimulators):

Indication ONE-of: Complex regional pain syndrome (CRPS); Painful diabetic neuropathy; Failed back surgery syndrome.

Device is implanted and used in accordance with the U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings, and precautions for the specific device.

For medical necessity clinical coverage criteria, the individual must meet the applicable InterQual® CP: Procedures, Spinal Cord Stimulator (SCS) Insertion criteria (refer to InterQual®).

Covered when ALL of the following are met (Dorsal Root Ganglion (DRG) stimulation)

Covered when ALL of the following are met (Dorsal Root Ganglion (DRG) stimulation):

Not Medically Necessary / Unproven Indications

Not medically necessary / Unproven (DRG stimulation)

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

All other conditions not listed as proven (beyond CRPS I/II)

Provider Actions / Prior Authorization & Documentation

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Records should include a complete relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Medical history (including prior treatments, response to therapy, duration of symptoms)
Physical examination findings relevant to the pain condition
Diagnostic test results (imaging, electrodiagnostic studies, laboratory tests) and procedure reports

Prior Authorization

InterQual criteria / SCS trial requirement

Medical necessity is determined per InterQual® CP: Procedures, Spinal Cord Stimulator (SCS) Insertion. An SCS trial is recommended (and may be required for coverage) to document clinically meaningful pain relief prior to permanent implantation, except when the indication is anginal pain where a trial may not be required.

Coding

Referenced CPT codes (procedures)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.

Referenced HCPCS codes (implanted devices/accessories)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.

Referenced FDA product codes (informational)mixed

LGW	PMA product code for implantable spinal cord stimulation systems
GZB	PMA product code for implantable spinal cord stimulation systems
GZF	510(k) product code for spinal cord stimulation devices
PMP	Product code search category for devices used for DRG stimulation

Background & Evidence Summary

The policy addresses use of implanted SCS and DRG stimulation for chronic pain and refers providers to InterQual clinical criteria for SCS insertion to assess medical necessity. It summarizes external evidence reviews (Hayes, ECRI) and cites randomized controlled trials and systematic reviews — including the ACCURATE randomized comparative trial and pooled/meta-analyses — that evaluate effectiveness and safety of SCS and DRG stimulation across indications such as CRPS, diabetic neuropathy, failed back surgery syndrome, and other chronic pain conditions.

Evidence / Source	Key finding
InterQual CP (referenced in policy for medical necessity)
Primary medical necessity clinical coverage criteria for SCS insertion; InterQual CP used as the reference to determine coverage
Hayes / ECRI reviews
Multiple evidence assessments (Hayes, ECRI) summarized RCTs, systematic reviews, and observational studies for SCS and DRG stimulation across indications; Hayes updated DRG review found limited, very low-quality evidence but suggested benefit for CRPS; ECRI assessments report safety and effectiveness signals for several SCS modalities with limitations (risk of bias, small studies)
ACCURATE trial (Deer et al., 2017)
Randomized comparative trial (n=152) in CRPS/causalgia of lower extremities: DRG arm treatment success (≥50% pain relief without stimulation-related neurological deficits) 81.2% vs SCS 55.7% at 3 months; no stimulation-related neurological deficits; DRG improved QOL and had less postural variation in paresthesia
Huygen pooled analysis (2020)
Pooled analysis of studies (217 participants with permanent implant at 12 months): overall weighted mean pain score 3.4 and 63% reported ≥50% pain relief; responder rates by location: foot/groin 80%, leg 75%, back 70%; common complications: IPG pocket pain, lead fracture/migration, infection
Vuka systematic review (2019)
Systematic review of 29 studies (one RCT; median study size small, range 1–152) concluded evidence positive but largely inconclusive due to small participant numbers and poor study quality; DRG may help highly selected patients who failed other therapies
ASRAPM 2023 guidance
Recommendation that an SCS trial be performed before definitive implant except for anginal pain; patients should be screened with validated psychosocial instruments and selection consider predictors of poor response—supports trial requirement noted in policy

Definitions

Glossary: SCS — Spinal Cord Stimulation: implanted electrical stimulator systems for chronic pain relief. DRG — Dorsal Root Ganglion stimulation: neuromodulation targeting dorsal root ganglia for treatment of chronic pain syndromes. InterQual CP — InterQual clinical criteria: proprietary criteria used to determine medical necessity for procedures (refer to InterQual CP: Procedures, Spinal Cord Stimulator (SCS) Insertion).

Revision History

2026-02-01revisedLatest

Revised list of proven and medically necessary conditions: replaced 'painful lower limb diabetic neuropathy' with 'painful diabetic neuropathy'; clarified DRG stimulation coverage language to remove the 'refractory' qualifier and state DRG stimulation is proven and medically necessary for treating CRPS I and II when performed according to FDA-labeled indications, contraindications, warnings, and precautions.

2026-02-01revised

Replaced prior DRG wording indicating coverage for 'refractory' CRPS with wording that 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.

Policy Summary

PayerUnitedHealthcare

PolicyImplanted Electrical Stimulator Spinal Cord Ks Cs

Policy CodePolicy CS061KS.02

Change TypeRevisions to covered indicationsDRG wording clarified

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity (history, exam, diagnostics) and meet InterQual SCS insertion criteria for coverage consideration.

SourceLink

On This Page

Trial Stimulation Recommendation (Guidance from ASRAPM and FDA advisory referenced)

Trial Stimulation Recommendation (Guidance from ASRAPM and FDA advisory referenced):

AnSCS trial is recommended to be performed prior to definitive implantation for pain indications except when the indication is refractory anginal pain (anginal pain is an exception where trial may not be required).

Psychosocial screening should be performed prior to trial and/or permanent implant to assess factors (for example, uncontrolled psychiatric illness, substance use disorder, unrealistic expectations) that may predict poor response to SCS.

Patient selection should consider prior therapies, concordant pain distribution, prior spine surgery status (when applicable), and overall goals of care.

Documentation of the trial stimulation response and psychosocial assessment must be available to support medical necessity for permanent implantation.

Billing Rule

Code listing is for reference only

The CPT and HCPCS codes listed are provided for reference only and inclusion does not guarantee coverage or payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws. Providers must verify member benefits and payer-specific requirements; the presence of a code in this policy is not a guarantee of reimbursement.

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
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