CMM-211: Spinal Cord and Dorsal Root Ganglion Stimulation

Policy covers >48‑hour SCS trials and, if trial pain reduction is ≥50%, permanent implantation of SCS (non‑high‑frequency and HF10 for FBSS) for failed back surgery syndrome with neuropathic leg pain, CRPS limited to the extremities, chronic critical limb ischemia, chronic stable angina, and select replacements; it excludes/labels as experimental DRG stimulation (except limited replacements), peripheral nerve stimulation, burst and other non‑tonic modes, high‑frequency or other SCS uses for all other indications, and numerous listed conditions. Key requirements include >48‑hour trial and ≥50% trial pain reduction for implantation, documentation of prior spine surgery and ≥6 months physician‑supervised conservative management where specified, behavioral‑health attestation of no uncontrolled mental/behavioral issues, vascular/cardiac specialist attestations and objective vascular/angiographic criteria for CLI, and cardiologist attestations plus failed optimal medical therapy for angina; replacements require device malfunction/unrepairability.