C1826, Generator, neurostimulator (implantable), includes closed feedback loop leads
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- SCS is medically necessary for severe, chronic trunk/limb pain refractory to all other therapies if: (a) other modalities have been tried/are unsuitable or contraindicated; (b) no significant untreated drug habituation or addiction; and (c) at least 50% pain relief from trial electrode implantation prior to permanent implantation.
- Medically necessary SCS for severe, chronic trunk/limb pain refractory to other therapies when: (1) other modalities have been tried and failed or are unsuitable/contraindicated; (2) no significant untreated drug habituation or addiction; (3) at least 50% pain relief during trial prior to permanent implantation.
- Spinal cord stimulation may be considered medically necessary for treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies, when: (1) other modalities have been tried and failed or are unsuitable; (2) no significant untreated drug habituation or addiction; and (3) at least 50% pain relief from trial electrode implantation prior to permanent implantation.
- Short-term trial of spinal cord stimulation (standard or high frequency) may be medically necessary when criteria listed for specific conditions are met.
5 Active Policies
BCBSIL-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSMT-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSNM-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
BCBSOK-SUR712.009, Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation
REGENCE-SUR45a, Spinal Cord and Dorsal Root Ganglion Stimulation
Related Codes
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