Aetna · Clinical coverage policy

Aetna Spinal Cord Stimulation (Dorsal Column Stimulation) coverage criteria

Aetna covers spinal cord (dorsal column) stimulation for a narrow set of chronic pain conditions — failed back surgery syndrome with radicular pain, CRPS types 1 and 2, inoperable chronic ischemic limb pain, certain chronic neuropathic pain of specific origins, and intractable angina — only after the patient passes a multidisciplinary (including psychological) screening, has failed at least 6 months of conservative therapy, scores an ODI of 21% or greater, has clear imaging, and achieves 50% or more pain relief in a 3- to 7-day percutaneous trial before permanent implant. Nearly all other chronic pain indications, several newer device technologies (e.g., Nalu micro-IPG), and combined/dual-stimulator configurations are considered experimental/investigational or not medically necessary, and the bulletin does not address whether precertification is required.

Policy CPB 0194 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0194

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0194 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Spinal Cord Stimulation (Dorsal Column Stimulation) (CPT 63650), and what gets it denied?

Path
Aetna covers spinal cord (dorsal column) stimulation for a narrow set of chronic pain conditions — failed back surgery syndrome with radicular pain, CRPS types 1 and 2, inoperable chronic ischemic limb pain, certain chronic neuropathic pain of specific origins, and intractable angina — only after the patient passes a multidisciplinary (including psychological) screening, has failed at least 6 months of conservative therapy, scores an ODI of 21% or greater, has clear imaging, and achieves 50% or more pain relief in a 3- to 7-day percutaneous trial before permanent implant. Nearly all other chronic pain indications, several newer device technologies (e.g., Nalu micro-IPG), and combined/dual-stimulator configurations are considered experimental/investigational or not medically necessary, and the bulletin does not address whether precertification is required. Coverage criteria include: Trial of percutaneous dorsal column stimulation (DCS) for chronic pain is medically necessary when ALL of the criteria below are met AND the member has ONE of the following qualifying indications: (a) Failed back surgery syndrome (FBSS) with low back pain and significant radicular pain; OR (b) Complex regional pain syndrome (CRPS) types 1 and 2; OR (c) Inoperable chronic ischemic limb pain secondary to peripheral vascular disease; OR (d) Last resort treatment of moderate-to-severe (5+ on 10-point VAS) chronic neuropathic pain of certain origins: lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy (including diabetic), post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy (present 12+ months); Trial of percutaneous DCS criterion (ALL required): Member has undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation (Note: screening must include psychological as well as physical evaluations); Trial of percutaneous DCS criterion (ALL required): Member does not have any untreated existing substance use disorder(s) (per American Society of Addiction Medicine (ASAM) guidelines); Trial of percutaneous DCS criterion (ALL required): Member has obtained clearance from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker); Trial of percutaneous DCS criterion (ALL required): Other more conservative methods of pain management have been tried and failed for a minimum of 6 months (including at least three of the following classes of medications: non-steroidal anti-inflammatory drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), muscle relaxants (Tizanidine, Cyclobenzaprine, Baclofen), and anticonvulsants) AND physical therapy (formal in-person (not virtual) physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year) AND psychological therapies; Trial of percutaneous DCS criterion (ALL required): If the member has had spinal surgery, they are at least 6 months post-operative; Trial of percutaneous DCS criterion (ALL required): Member's functional disability assessed using the Oswestry Disability Index (ODI); member has received an ODI score greater than or equal to 21%; Trial of percutaneous DCS criterion (ALL required): Advanced imaging studies (CT or MRI) of the thoracic spine levels indicate that there are no anatomic contraindications for lead placement; Trial of percutaneous DCS criterion (ALL required): All other reasonable sources of pain have been ruled out including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report; Trial of percutaneous DCS criterion (ALL required): For FBSS only - advanced imaging studies (CT or MRI) demonstrate prior spinal surgery; Implantation of a dorsal column stimulator (DCS) for members who meet the above-listed criteria who have experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation as evidenced by trial placement and lead pull note; The use of cervical dorsal column stimulation for the treatment of members with complex regional pain syndrome when criteria in Section A are met AND the member has experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation; DCS for intractable angina pectoris is medically necessary when ALL of the following are met: (1) Member experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation (a trial of percutaneous spinal stimulation is considered medically necessary for members who meet the above-listed criteria, in order to predict whether a dorsal column stimulator will induce significant pain relief); (2) Member has angiographically documented significant coronary artery disease and is not a suitable candidate for revascularization procedures such as coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA); (3) Member has had optimal pharmacotherapy for at least one month — optimal pharmacotherapy includes the maximal tolerated dosages of at least 2 of the following anti-anginal medications: long-acting nitrates, beta-adrenergic blockers, or calcium channel antagonists; (4) Member's angina pectoris is New York Heart Association (NYHA) Functional Class III or Class IV; (5) Reversible ischemia is documented by symptom-limited treadmill exercise test; Dorsal column stimulators using high-frequency spinal cord stimulation (Senza), burst stimulation (BurstDR), or differential target multiplexed stimulation (Medtronic DTM) are considered equally effective alternatives to standard dorsal column stimulators for the indications listed above; Replacement of a cervical, lumbar or thoracic dorsal column stimulator or battery/generator for individuals who have had a positive pain relief response from the existing DCS AND the existing stimulator or battery/generator has undergone interrogation by the Manufacturer representative to document implantable pulse generator (IPG) 'end of life' or that it cannot be repaired; If a spinal cord stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure (e.g., including but not limited to lead migration, infection, anatomic difficulties); Removal of dorsal column stimulator even where installation would not have been indicated; A spinal cord stimulator patient programmer for members who meet criteria for a dorsal column stimulator; Up to 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead is considered medically necessary for a dorsal column stimulator trial; AND up to 16 electrodes/contacts or 4 percutaneous leads is considered medically necessary for a dorsal root ganglion stimulator trial; Dorsal root ganglion stimulators (e.g., Axium Neurostimulator System) for moderate-to-severe chronic intractable pain of the lower limbs in persons with complex regional pain syndrome (CRPS) types I and II, when general medical necessity criteria for spinal cord stimulators in Section A are met; Revision/replacement of a previously implanted stimulator for ANY of the following: (a) Lead malfunction (e.g., fracture or migration); OR (b) Prior device removal for infection with consult from an infectious disease specialist to confirm infection has been eradicated; OR (c) If member has a documented need for an MRI-compatible device due to contraindications to CT/myelography; Closed-loop spinal cord stimulation system is considered equivalent to a standard spinal cord stimulation system; If a dorsal root ganglion stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure. Applies to 23 codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, C1767, C1778, C1787, C1820, C1822, L8679, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Multidisciplinary screening, evaluation, and diagnosis documentation including psychological as well as physical evaluations, completed prior to implantation; Mental health clearance documentation from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker); Documentation of failed conservative pain management for a minimum of 6 months, including at least three classes of medications and formal in-person physical therapy (minimum 6 weeks within the past year) and psychological therapies; Oswestry Disability Index (ODI) score documentation (must be greater than or equal to 21%); Advanced imaging studies (CT or MRI) of the thoracic spine documenting no anatomic contraindications for lead placement, and ruling out other reasonable sources of pain; For FBSS only: advanced imaging studies (CT or MRI) documenting prior spinal surgery; Trial placement and lead pull note documenting significant pain reduction (50% or more) during the 3- to 7-day percutaneous trial; For intractable angina: angiographically documented significant coronary artery disease, NYHA Functional Class III or IV assessment, and reversible ischemia documented by symptom-limited treadmill exercise test; For device/battery replacement: Manufacturer representative interrogation documentation of IPG 'end of life' status or that it cannot be repaired; For infection-related revision/replacement: consult documentation from an infectious disease specialist confirming infection has been eradicated.
Trap
Policy exclusions and limitations: Replacement of a functioning standard dorsal column stimulator with a high-frequency, burst dorsal column, or DTM stimulator is considered not medically necessary; A change in battery for spinal cord stimulator because of paresthesia is considered not medically necessary; The use of electrode/contact or lead quantities exceeding the stated limits (more than 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead for a DCS trial; more than 16 electrodes/contacts or 4 percutaneous leads for a dorsal root ganglion stimulator trial) for either trial or implantation is not considered medically necessary, as current peer-reviewed evidence does not demonstrate that configurations beyond standard counts improve pain relief, functional outcomes, or durability of benefit; The use of cervical dorsal column stimulation for the treatment of members with cervical trauma, disc herniation, essential tremor, failed cervical spine surgery syndrome presenting with arm pain, neck pain, cervicogenic headache, gliomas, migraine, radiation-induced brain injury, stroke, trigeminal neuropathy, or any other indication (other than CRPS) is considered experimental/investigational; Dorsal column stimulation for all other indications not mentioned above, including (not an all-inclusive list): Management of pain associated with chronic pancreatitis; Dorsal column stimulation for: Treatment of persons in a chronic vegetative or minimally conscious state; Dorsal column stimulation for: Abdominal pain related to celiac artery compression syndrome; Dorsal column stimulation for: Alcoholic neuropathy; Dorsal column stimulation for: Chest wall/sternal pain; Dorsal column stimulation for: Chronic abdominal pain; Dorsal column stimulation for: Chronic malignant pain; Dorsal column stimulation for: Chronic pelvic pain; Dorsal column stimulation for: Chronic visceral pain; Dorsal column stimulation for: Coccydynia; Dorsal column stimulation for: Complex regional pain syndrome (CRPS) of other sites besides the upper and lower extremities (including but not limited to the head and abdomen); Dorsal column stimulation for: Disorders of consciousness; Dorsal column stimulation for: Gait and balance disorders (including multi-system atrophy, Parkinson's disease, progressive supranuclear palsy, and spinocerebellar ataxia); Dorsal column stimulation for: Gastroparesis; Dorsal column stimulation for: Guillain Barre syndrome; Dorsal column stimulation for: Irritable bowel syndrome; Dorsal column stimulation for: Meralgia paresthetica; Dorsal column stimulation for: Neurodegenerative ataxia; Dorsal column stimulation for: Neuropathic pain associated with multiple sclerosis; Dorsal column stimulation for: Orthostatic tremor; Dorsal column stimulation for: Parkinson's disease; Dorsal column stimulation for: Peri-rectal pain; Dorsal column stimulation for: Sleep disorders; Dorsal column stimulation for: Sphincter of Oddi dysfunction; Dorsal column stimulation for: Types of chronic non-malignant non-neuropathic pain not mentioned above; Dorsal column stimulation for: Ventricular fibrillation; Dorsal column stimulation for: Ventricular tachycardia; The Nalu micro-IPG for spinal cord stimulation is considered experimental/investigational; The use of intra-operative motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) for implantation of spinal cord stimulators is considered experimental/investigational; Dorsal root ganglion stimulators for all other indications (e.g., treatment of chronic pelvic pain, failed back surgery syndrome, and meralgia paresthetica) are considered experimental/investigational; The concurrent use of 2 dorsal column stimulators for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; The combined use of dorsal column stimulation and dorsal root ganglion stimulation for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; Transcutaneous spinal cord stimulation for motor rehabilitation in individuals with spinal cord injury is considered experimental/investigational. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0194 — Spinal Cord Stimulation (Dorsal Column Stimulation)

Coverage criteria

  • Trial of percutaneous dorsal column stimulation (DCS) for chronic pain is medically necessary when ALL of the criteria below are met AND the member has ONE of the following qualifying indications: (a) Failed back surgery syndrome (FBSS) with low back pain and significant radicular pain; OR (b) Complex regional pain syndrome (CRPS) types 1 and 2; OR (c) Inoperable chronic ischemic limb pain secondary to peripheral vascular disease; OR (d) Last resort treatment of moderate-to-severe (5+ on 10-point VAS) chronic neuropathic pain of certain origins: lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy (including diabetic), post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy (present 12+ months)
  • Trial of percutaneous DCS criterion (ALL required): Member has undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation (Note: screening must include psychological as well as physical evaluations)
  • Trial of percutaneous DCS criterion (ALL required): Member does not have any untreated existing substance use disorder(s) (per American Society of Addiction Medicine (ASAM) guidelines)
  • Trial of percutaneous DCS criterion (ALL required): Member has obtained clearance from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker)
  • Trial of percutaneous DCS criterion (ALL required): Other more conservative methods of pain management have been tried and failed for a minimum of 6 months (including at least three of the following classes of medications: non-steroidal anti-inflammatory drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), muscle relaxants (Tizanidine, Cyclobenzaprine, Baclofen), and anticonvulsants) AND physical therapy (formal in-person (not virtual) physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year) AND psychological therapies
  • Trial of percutaneous DCS criterion (ALL required): If the member has had spinal surgery, they are at least 6 months post-operative
  • Trial of percutaneous DCS criterion (ALL required): Member's functional disability assessed using the Oswestry Disability Index (ODI); member has received an ODI score greater than or equal to 21%
  • Trial of percutaneous DCS criterion (ALL required): Advanced imaging studies (CT or MRI) of the thoracic spine levels indicate that there are no anatomic contraindications for lead placement
  • Trial of percutaneous DCS criterion (ALL required): All other reasonable sources of pain have been ruled out including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report
  • Trial of percutaneous DCS criterion (ALL required): For FBSS only - advanced imaging studies (CT or MRI) demonstrate prior spinal surgery
  • Implantation of a dorsal column stimulator (DCS) for members who meet the above-listed criteria who have experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation as evidenced by trial placement and lead pull note
  • The use of cervical dorsal column stimulation for the treatment of members with complex regional pain syndrome when criteria in Section A are met AND the member has experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation
  • DCS for intractable angina pectoris is medically necessary when ALL of the following are met: (1) Member experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation (a trial of percutaneous spinal stimulation is considered medically necessary for members who meet the above-listed criteria, in order to predict whether a dorsal column stimulator will induce significant pain relief); (2) Member has angiographically documented significant coronary artery disease and is not a suitable candidate for revascularization procedures such as coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA); (3) Member has had optimal pharmacotherapy for at least one month — optimal pharmacotherapy includes the maximal tolerated dosages of at least 2 of the following anti-anginal medications: long-acting nitrates, beta-adrenergic blockers, or calcium channel antagonists; (4) Member's angina pectoris is New York Heart Association (NYHA) Functional Class III or Class IV; (5) Reversible ischemia is documented by symptom-limited treadmill exercise test
  • Dorsal column stimulators using high-frequency spinal cord stimulation (Senza), burst stimulation (BurstDR), or differential target multiplexed stimulation (Medtronic DTM) are considered equally effective alternatives to standard dorsal column stimulators for the indications listed above
  • Replacement of a cervical, lumbar or thoracic dorsal column stimulator or battery/generator for individuals who have had a positive pain relief response from the existing DCS AND the existing stimulator or battery/generator has undergone interrogation by the Manufacturer representative to document implantable pulse generator (IPG) 'end of life' or that it cannot be repaired
  • If a spinal cord stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure (e.g., including but not limited to lead migration, infection, anatomic difficulties)
  • Removal of dorsal column stimulator even where installation would not have been indicated
  • A spinal cord stimulator patient programmer for members who meet criteria for a dorsal column stimulator
  • Up to 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead is considered medically necessary for a dorsal column stimulator trial; AND up to 16 electrodes/contacts or 4 percutaneous leads is considered medically necessary for a dorsal root ganglion stimulator trial
  • Dorsal root ganglion stimulators (e.g., Axium Neurostimulator System) for moderate-to-severe chronic intractable pain of the lower limbs in persons with complex regional pain syndrome (CRPS) types I and II, when general medical necessity criteria for spinal cord stimulators in Section A are met
  • Revision/replacement of a previously implanted stimulator for ANY of the following: (a) Lead malfunction (e.g., fracture or migration); OR (b) Prior device removal for infection with consult from an infectious disease specialist to confirm infection has been eradicated; OR (c) If member has a documented need for an MRI-compatible device due to contraindications to CT/myelography
  • Closed-loop spinal cord stimulation system is considered equivalent to a standard spinal cord stimulation system
  • If a dorsal root ganglion stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Multidisciplinary screening, evaluation, and diagnosis documentation including psychological as well as physical evaluations, completed prior to implantation
  • Mental health clearance documentation from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker)
  • Documentation of failed conservative pain management for a minimum of 6 months, including at least three classes of medications and formal in-person physical therapy (minimum 6 weeks within the past year) and psychological therapies
  • Oswestry Disability Index (ODI) score documentation (must be greater than or equal to 21%)
  • Advanced imaging studies (CT or MRI) of the thoracic spine documenting no anatomic contraindications for lead placement, and ruling out other reasonable sources of pain
  • For FBSS only: advanced imaging studies (CT or MRI) documenting prior spinal surgery
  • Trial placement and lead pull note documenting significant pain reduction (50% or more) during the 3- to 7-day percutaneous trial
  • For intractable angina: angiographically documented significant coronary artery disease, NYHA Functional Class III or IV assessment, and reversible ischemia documented by symptom-limited treadmill exercise test
  • For device/battery replacement: Manufacturer representative interrogation documentation of IPG 'end of life' status or that it cannot be repaired
  • For infection-related revision/replacement: consult documentation from an infectious disease specialist confirming infection has been eradicated

Frequently asked questions

When does Aetna cover Spinal Cord Stimulation (Dorsal Column Stimulation) (CPT 63650), and what gets it denied?
Aetna covers spinal cord (dorsal column) stimulation for a narrow set of chronic pain conditions — failed back surgery syndrome with radicular pain, CRPS types 1 and 2, inoperable chronic ischemic limb pain, certain chronic neuropathic pain of specific origins, and intractable angina — only after the patient passes a multidisciplinary (including psychological) screening, has failed at least 6 months of conservative therapy, scores an ODI of 21% or greater, has clear imaging, and achieves 50% or more pain relief in a 3- to 7-day percutaneous trial before permanent implant. Nearly all other chronic pain indications, several newer device technologies (e.g., Nalu micro-IPG), and combined/dual-stimulator configurations are considered experimental/investigational or not medically necessary, and the bulletin does not address whether precertification is required. Coverage criteria include: Trial of percutaneous dorsal column stimulation (DCS) for chronic pain is medically necessary when ALL of the criteria below are met AND the member has ONE of the following qualifying indications: (a) Failed back surgery syndrome (FBSS) with low back pain and significant radicular pain; OR (b) Complex regional pain syndrome (CRPS) types 1 and 2; OR (c) Inoperable chronic ischemic limb pain secondary to peripheral vascular disease; OR (d) Last resort treatment of moderate-to-severe (5+ on 10-point VAS) chronic neuropathic pain of certain origins: lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy (including diabetic), post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy (present 12+ months); Trial of percutaneous DCS criterion (ALL required): Member has undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation (Note: screening must include psychological as well as physical evaluations); Trial of percutaneous DCS criterion (ALL required): Member does not have any untreated existing substance use disorder(s) (per American Society of Addiction Medicine (ASAM) guidelines); Trial of percutaneous DCS criterion (ALL required): Member has obtained clearance from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker); Trial of percutaneous DCS criterion (ALL required): Other more conservative methods of pain management have been tried and failed for a minimum of 6 months (including at least three of the following classes of medications: non-steroidal anti-inflammatory drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), muscle relaxants (Tizanidine, Cyclobenzaprine, Baclofen), and anticonvulsants) AND physical therapy (formal in-person (not virtual) physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year) AND psychological therapies; Trial of percutaneous DCS criterion (ALL required): If the member has had spinal surgery, they are at least 6 months post-operative; Trial of percutaneous DCS criterion (ALL required): Member's functional disability assessed using the Oswestry Disability Index (ODI); member has received an ODI score greater than or equal to 21%; Trial of percutaneous DCS criterion (ALL required): Advanced imaging studies (CT or MRI) of the thoracic spine levels indicate that there are no anatomic contraindications for lead placement; Trial of percutaneous DCS criterion (ALL required): All other reasonable sources of pain have been ruled out including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report; Trial of percutaneous DCS criterion (ALL required): For FBSS only - advanced imaging studies (CT or MRI) demonstrate prior spinal surgery; Implantation of a dorsal column stimulator (DCS) for members who meet the above-listed criteria who have experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation as evidenced by trial placement and lead pull note; The use of cervical dorsal column stimulation for the treatment of members with complex regional pain syndrome when criteria in Section A are met AND the member has experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation; DCS for intractable angina pectoris is medically necessary when ALL of the following are met: (1) Member experienced significant pain reduction (50% or more) with a 3- to 7-day trial of percutaneous spinal stimulation (a trial of percutaneous spinal stimulation is considered medically necessary for members who meet the above-listed criteria, in order to predict whether a dorsal column stimulator will induce significant pain relief); (2) Member has angiographically documented significant coronary artery disease and is not a suitable candidate for revascularization procedures such as coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA); (3) Member has had optimal pharmacotherapy for at least one month — optimal pharmacotherapy includes the maximal tolerated dosages of at least 2 of the following anti-anginal medications: long-acting nitrates, beta-adrenergic blockers, or calcium channel antagonists; (4) Member's angina pectoris is New York Heart Association (NYHA) Functional Class III or Class IV; (5) Reversible ischemia is documented by symptom-limited treadmill exercise test; Dorsal column stimulators using high-frequency spinal cord stimulation (Senza), burst stimulation (BurstDR), or differential target multiplexed stimulation (Medtronic DTM) are considered equally effective alternatives to standard dorsal column stimulators for the indications listed above; Replacement of a cervical, lumbar or thoracic dorsal column stimulator or battery/generator for individuals who have had a positive pain relief response from the existing DCS AND the existing stimulator or battery/generator has undergone interrogation by the Manufacturer representative to document implantable pulse generator (IPG) 'end of life' or that it cannot be repaired; If a spinal cord stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure (e.g., including but not limited to lead migration, infection, anatomic difficulties); Removal of dorsal column stimulator even where installation would not have been indicated; A spinal cord stimulator patient programmer for members who meet criteria for a dorsal column stimulator; Up to 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead is considered medically necessary for a dorsal column stimulator trial; AND up to 16 electrodes/contacts or 4 percutaneous leads is considered medically necessary for a dorsal root ganglion stimulator trial; Dorsal root ganglion stimulators (e.g., Axium Neurostimulator System) for moderate-to-severe chronic intractable pain of the lower limbs in persons with complex regional pain syndrome (CRPS) types I and II, when general medical necessity criteria for spinal cord stimulators in Section A are met; Revision/replacement of a previously implanted stimulator for ANY of the following: (a) Lead malfunction (e.g., fracture or migration); OR (b) Prior device removal for infection with consult from an infectious disease specialist to confirm infection has been eradicated; OR (c) If member has a documented need for an MRI-compatible device due to contraindications to CT/myelography; Closed-loop spinal cord stimulation system is considered equivalent to a standard spinal cord stimulation system; If a dorsal root ganglion stimulation trial fails, a repeat trial is medically necessary ONLY if there are extenuating circumstances that lead to trial failure. Applies to 23 codes: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, C1767, C1778, C1787, C1820, C1822, L8679, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Multidisciplinary screening, evaluation, and diagnosis documentation including psychological as well as physical evaluations, completed prior to implantation; Mental health clearance documentation from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker); Documentation of failed conservative pain management for a minimum of 6 months, including at least three classes of medications and formal in-person physical therapy (minimum 6 weeks within the past year) and psychological therapies; Oswestry Disability Index (ODI) score documentation (must be greater than or equal to 21%); Advanced imaging studies (CT or MRI) of the thoracic spine documenting no anatomic contraindications for lead placement, and ruling out other reasonable sources of pain; For FBSS only: advanced imaging studies (CT or MRI) documenting prior spinal surgery; Trial placement and lead pull note documenting significant pain reduction (50% or more) during the 3- to 7-day percutaneous trial; For intractable angina: angiographically documented significant coronary artery disease, NYHA Functional Class III or IV assessment, and reversible ischemia documented by symptom-limited treadmill exercise test; For device/battery replacement: Manufacturer representative interrogation documentation of IPG 'end of life' status or that it cannot be repaired; For infection-related revision/replacement: consult documentation from an infectious disease specialist confirming infection has been eradicated. Policy exclusions and limitations: Replacement of a functioning standard dorsal column stimulator with a high-frequency, burst dorsal column, or DTM stimulator is considered not medically necessary; A change in battery for spinal cord stimulator because of paresthesia is considered not medically necessary; The use of electrode/contact or lead quantities exceeding the stated limits (more than 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead for a DCS trial; more than 16 electrodes/contacts or 4 percutaneous leads for a dorsal root ganglion stimulator trial) for either trial or implantation is not considered medically necessary, as current peer-reviewed evidence does not demonstrate that configurations beyond standard counts improve pain relief, functional outcomes, or durability of benefit; The use of cervical dorsal column stimulation for the treatment of members with cervical trauma, disc herniation, essential tremor, failed cervical spine surgery syndrome presenting with arm pain, neck pain, cervicogenic headache, gliomas, migraine, radiation-induced brain injury, stroke, trigeminal neuropathy, or any other indication (other than CRPS) is considered experimental/investigational; Dorsal column stimulation for all other indications not mentioned above, including (not an all-inclusive list): Management of pain associated with chronic pancreatitis; Dorsal column stimulation for: Treatment of persons in a chronic vegetative or minimally conscious state; Dorsal column stimulation for: Abdominal pain related to celiac artery compression syndrome; Dorsal column stimulation for: Alcoholic neuropathy; Dorsal column stimulation for: Chest wall/sternal pain; Dorsal column stimulation for: Chronic abdominal pain; Dorsal column stimulation for: Chronic malignant pain; Dorsal column stimulation for: Chronic pelvic pain; Dorsal column stimulation for: Chronic visceral pain; Dorsal column stimulation for: Coccydynia; Dorsal column stimulation for: Complex regional pain syndrome (CRPS) of other sites besides the upper and lower extremities (including but not limited to the head and abdomen); Dorsal column stimulation for: Disorders of consciousness; Dorsal column stimulation for: Gait and balance disorders (including multi-system atrophy, Parkinson's disease, progressive supranuclear palsy, and spinocerebellar ataxia); Dorsal column stimulation for: Gastroparesis; Dorsal column stimulation for: Guillain Barre syndrome; Dorsal column stimulation for: Irritable bowel syndrome; Dorsal column stimulation for: Meralgia paresthetica; Dorsal column stimulation for: Neurodegenerative ataxia; Dorsal column stimulation for: Neuropathic pain associated with multiple sclerosis; Dorsal column stimulation for: Orthostatic tremor; Dorsal column stimulation for: Parkinson's disease; Dorsal column stimulation for: Peri-rectal pain; Dorsal column stimulation for: Sleep disorders; Dorsal column stimulation for: Sphincter of Oddi dysfunction; Dorsal column stimulation for: Types of chronic non-malignant non-neuropathic pain not mentioned above; Dorsal column stimulation for: Ventricular fibrillation; Dorsal column stimulation for: Ventricular tachycardia; The Nalu micro-IPG for spinal cord stimulation is considered experimental/investigational; The use of intra-operative motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) for implantation of spinal cord stimulators is considered experimental/investigational; Dorsal root ganglion stimulators for all other indications (e.g., treatment of chronic pelvic pain, failed back surgery syndrome, and meralgia paresthetica) are considered experimental/investigational; The concurrent use of 2 dorsal column stimulators for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; The combined use of dorsal column stimulation and dorsal root ganglion stimulation for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; Transcutaneous spinal cord stimulation for motor rehabilitation in individuals with spinal cord injury is considered experimental/investigational. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Spinal Cord Stimulation (Dorsal Column Stimulation)?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Multidisciplinary screening, evaluation, and diagnosis documentation including psychological as well as physical evaluations, completed prior to implantation; Mental health clearance documentation from a psychiatrist, psychologist, or other qualified mental health professional (e.g., Licensed Clinical Social Worker); Documentation of failed conservative pain management for a minimum of 6 months, including at least three classes of medications and formal in-person physical therapy (minimum 6 weeks within the past year) and psychological therapies; Oswestry Disability Index (ODI) score documentation (must be greater than or equal to 21%); Advanced imaging studies (CT or MRI) of the thoracic spine documenting no anatomic contraindications for lead placement, and ruling out other reasonable sources of pain; For FBSS only: advanced imaging studies (CT or MRI) documenting prior spinal surgery; Trial placement and lead pull note documenting significant pain reduction (50% or more) during the 3- to 7-day percutaneous trial; For intractable angina: angiographically documented significant coronary artery disease, NYHA Functional Class III or IV assessment, and reversible ischemia documented by symptom-limited treadmill exercise test; For device/battery replacement: Manufacturer representative interrogation documentation of IPG 'end of life' status or that it cannot be repaired; For infection-related revision/replacement: consult documentation from an infectious disease specialist confirming infection has been eradicated.
What does Aetna exclude for Spinal Cord Stimulation (Dorsal Column Stimulation)?
Policy exclusions and limitations: Replacement of a functioning standard dorsal column stimulator with a high-frequency, burst dorsal column, or DTM stimulator is considered not medically necessary; A change in battery for spinal cord stimulator because of paresthesia is considered not medically necessary; The use of electrode/contact or lead quantities exceeding the stated limits (more than 16 electrodes/contacts, 2 percutaneous leads, or 1 paddle lead for a DCS trial; more than 16 electrodes/contacts or 4 percutaneous leads for a dorsal root ganglion stimulator trial) for either trial or implantation is not considered medically necessary, as current peer-reviewed evidence does not demonstrate that configurations beyond standard counts improve pain relief, functional outcomes, or durability of benefit; The use of cervical dorsal column stimulation for the treatment of members with cervical trauma, disc herniation, essential tremor, failed cervical spine surgery syndrome presenting with arm pain, neck pain, cervicogenic headache, gliomas, migraine, radiation-induced brain injury, stroke, trigeminal neuropathy, or any other indication (other than CRPS) is considered experimental/investigational; Dorsal column stimulation for all other indications not mentioned above, including (not an all-inclusive list): Management of pain associated with chronic pancreatitis; Dorsal column stimulation for: Treatment of persons in a chronic vegetative or minimally conscious state; Dorsal column stimulation for: Abdominal pain related to celiac artery compression syndrome; Dorsal column stimulation for: Alcoholic neuropathy; Dorsal column stimulation for: Chest wall/sternal pain; Dorsal column stimulation for: Chronic abdominal pain; Dorsal column stimulation for: Chronic malignant pain; Dorsal column stimulation for: Chronic pelvic pain; Dorsal column stimulation for: Chronic visceral pain; Dorsal column stimulation for: Coccydynia; Dorsal column stimulation for: Complex regional pain syndrome (CRPS) of other sites besides the upper and lower extremities (including but not limited to the head and abdomen); Dorsal column stimulation for: Disorders of consciousness; Dorsal column stimulation for: Gait and balance disorders (including multi-system atrophy, Parkinson's disease, progressive supranuclear palsy, and spinocerebellar ataxia); Dorsal column stimulation for: Gastroparesis; Dorsal column stimulation for: Guillain Barre syndrome; Dorsal column stimulation for: Irritable bowel syndrome; Dorsal column stimulation for: Meralgia paresthetica; Dorsal column stimulation for: Neurodegenerative ataxia; Dorsal column stimulation for: Neuropathic pain associated with multiple sclerosis; Dorsal column stimulation for: Orthostatic tremor; Dorsal column stimulation for: Parkinson's disease; Dorsal column stimulation for: Peri-rectal pain; Dorsal column stimulation for: Sleep disorders; Dorsal column stimulation for: Sphincter of Oddi dysfunction; Dorsal column stimulation for: Types of chronic non-malignant non-neuropathic pain not mentioned above; Dorsal column stimulation for: Ventricular fibrillation; Dorsal column stimulation for: Ventricular tachycardia; The Nalu micro-IPG for spinal cord stimulation is considered experimental/investigational; The use of intra-operative motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) for implantation of spinal cord stimulators is considered experimental/investigational; Dorsal root ganglion stimulators for all other indications (e.g., treatment of chronic pelvic pain, failed back surgery syndrome, and meralgia paresthetica) are considered experimental/investigational; The concurrent use of 2 dorsal column stimulators for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; The combined use of dorsal column stimulation and dorsal root ganglion stimulation for the treatment of complex regional pain syndrome or any other indications is considered experimental/investigational; Transcutaneous spinal cord stimulation for motor rehabilitation in individuals with spinal cord injury is considered experimental/investigational. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0194 — Spinal Cord Stimulation (Dorsal Column Stimulation)

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0194 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.