CMM-211: Spinal Cord Stimulators

Evicore covers short-term trials (>48 hrs) and permanent implantation of non‑high‑frequency spinal cord stimulators and HF10 SCS for failed back surgery syndrome with intractable neuropathic leg pain, CRPS/RSD, chronic critical limb ischemia, and chronic stable angina, while deeming dorsal root ganglion stimulation, peripheral nerve/field stimulation, generator modes other than tonic low/HF10 (e.g., burst), many other indications, and replacement of a functioning non‑HF device with an HF device investigational or not medically necessary. Key requirements include documented failure of conservative/surgical management (≥6 months for FBSS/CRPS), a mental health evaluation showing no uncontrolled psychiatric/substance issues, a short‑term trial demonstrating benefit (≥50% pain reduction for FBSS/CRPS; a documented “beneficial clinical response” for CLI/angina), and for angina CCS class III/IV plus cardiologist attestation that revascularization is not suitable (CRPS must also meet the guideline’s specified signs/symptoms criteria).