CMM-211: Spinal Cord and Dorsal Root Ganglion Stimulation

Cigna/EviCore covers short-term (>48 hr) trials and permanent implantation of non‑high‑frequency spinal cord stimulation (with HF10 allowed only for FBSS) for FBSS, extremity CRPS/RSD, chronic critical limb ischemia, and chronic stable angina, while excluding SCS/DRG for most other pain conditions (e.g., phantom limb, post‑herpetic neuralgia, diabetic neuropathy), disallowing burst and other non‑tonic modes, restricting DRG placement except for replacement, and prohibiting replacement of a functioning non‑HF SCS with a high‑frequency device. Coverage requires behavioral‑health attestation, documentation of failed conservative therapy (≥6 months for non‑angina pain), specialist attestations and objective vascular/cardiac criteria for CLI and angina, a successful trial (typically ≥50% pain reduction for FBSS/CRPS/CLI; a documented “beneficial” response for angina), trials >48 hrs, and replacements only for malfunction/irreparable/out‑of‑warranty devices.

"Chronic Intractable Pain Secondary to Failed Back Surgery Syndrome (FBSS) — spinal cord stimulation (non-high-frequency or high-frequency [HF10 SCS]) for treatment of chronic, intractable pain seco..."