CMM-211: Spinal Cord and Dorsal Root Ganglion Stimulation

This policy covers short-term trials (>48 hours) and permanent spinal cord stimulation implants for FBSS with neuropathic leg pain (HF10 allowed), extremity-limited CRPS/RSD, chronic critical limb ischemia, and chronic stable angina, while DRG stimulation (except replacement), peripheral nerve stimulation, HF‑SCS for non‑FBSS indications, non‑tonic/high-frequency generator modes (e.g., burst), dual‑mode/closed‑loop systems, and other listed uses are considered experimental/investigational or not medically necessary. Coverage requires a behavioral health attestation of no uncontrolled mental/behavioral conditions, typically ≥6 months of failed physician‑supervised conservative management (when applicable), indication‑specific objective criteria (e.g., Rutherford ankle/toe pressures and vascular imaging for CLI; CCS class III–IV and failed optimal medical therapy with cardiology attestation for angina), and ≥50% pain reduction during the >48‑hour trial to qualify for permanent implantation.