Spinal Cord Stimulation (SCS) and Dorsal Root Ganglion (DRG) Stimulation

This policy covers spinal cord stimulation (including standard and high‑frequency SCS) and dorsal root ganglion (DRG) neurostimulation for severe, chronic, refractory pain of the trunk or limbs — including neuropathic pain, failed back surgery syndrome, complex regional pain syndrome, radiculopathies, phantom/stump pain, peripheral and painful diabetic neuropathy, and similar refractory pain conditions. Coverage requires prior failure or unsuitability of other therapies and a temporary trial electrode demonstrating ≥50% pain relief before permanent implantation; nociceptive pain and multiple uses are excluded or considered experimental/investigational (e.g., certain cancer‑related pain, central deafferentation pain, refractory angina, some critical limb ischemia indications, and non–FDA‑cleared systems such as Wavegate StimuLux™).

"SCS (standard or high-frequency) or DRG neurostimulation for severe, chronic pain of the trunk or limbs that is refractory to all other pain therapies when other modalities have been tried and fail..."