S-285-002

HIGHMARK COMMERCIAL MEDICAL POLICY - NEW YORK

Medical Policy:

S-285-002

Topic:

Spinal Cord and Dorsal Root Ganglion Stimulation

Section:

Surgery

Effective Date:

February 9, 2026

Issued Date:

February 9, 2026

Last Revision Date:

December 2025

Annual Review:

December 2025

Spinal cord stimulation delivers low-voltage electrical stimulation to the dorsal columns of the spinal cord to block the sensation of pain; this is achieved through a surgically implanted spinal cord stimulation device, which comes equipped with a radiofrequency receiver. The neurostimulator device is also issued with a standard power source (battery) that can be implanted or worn externally. Other neurostimulators target the dorsal root ganglion.

Policy Position

A short-term trial (3-14 days) of spinal cord stimulation may be considered medically necessary for the treatment of severe and chronic (≥ 6 months) pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines and ALL of the following are met:

The treatment is used only as a last resort; other treatment modalities (guideline directed pharmacologic therapy [anticonvulsants such as gabapentin or pregabalin, antidepressants such as duloxetine or tricyclic antidepressants, topical agents], surgical, psychological, physical, if applicable) have been tried for at least six consecutive months and have failed or have been judged to be unsuitable or contraindicated; and
Pain is neuropathic in nature (ie, resulting from actual damage to the peripheral nerves). Note: Common indications include, but are not limited to, failed back surgery syndrome, complex regional pain syndrome (ie, reflex sympathetic dystrophy), arachnoiditis, radiculopathies, phantom limb/stump pain, peripheral neuropathy, and painful diabetic neuropathy. Spinal cord stimulation is generally not effective in treating nociceptive pain (resulting from irritation, not damage to the nerves) and central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury); and
A psychologic screen has been performed and shows no evidence of a co-existing mental health condition which would significantly influence the perception of pain or would likely compromise the success of spinal cord stimulation treatment; and
No untreated substance use disorder exists; and
All facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment, and follow-up of the individual are available.

Note: "Burst" neurostimulation is an alternate programming of a standard spinal cord stimulation device. A clinician programmer application is used to configure a standard spinal cord stimulation device to provide stimulation in "bursts" rather than at a constant ("tonic") rate.

Spinal cord stimulation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

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Permanent implantation of a spinal cord stimulator with standard or high-frequency stimulation may be considered medically necessary for the treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines and ALL of the following are met:

All criteria required for a short-term spinal cord stimulation trial has been met; and
The individual has reported ONE or more of the following during treatment with a temporarily implanted electrode
- Pain relief of at least 50%
- Functional improvement of at least 50% documented using a validated tool (e.g., Oswestry Disability Index [ODI], Brief Pain Inventory [BPI], Patient-Reported Outcomes Measurement Information System [PROMIS-29], etc.)
- Opioid use reduction of at least 50%

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A short-term trial (3-14 days) of dorsal root ganglion neurostimulation is considered medically necessary for the treatment of severe and chronic (≥ 6 months) pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines and ALL of the following are met:

The treatment is used only as a last resort; other treatment modalities (guideline directed pharmacologic therapy [anticonvulsants such as gabapentin or pregabalin, antidepressants such as duloxetine or tricyclic antidepressants, topical agents], surgical, psychological, physical, if applicable) have been tried for at least six consecutive months and have failed or have been judged to be unsuitable or contraindicated; and
Pain is neuropathic in nature (ie, resulting from actual damage to the peripheral nerves). Note: Common indications include, but are not limited to, failed back surgery syndrome, complex regional pain syndrome (ie, reflex sympathetic dystrophy), arachnoiditis, radiculopathies, phantom limb/stump pain, peripheral neuropathy, and painful diabetic neuropathy. Spinal cord stimulation is generally not effective in treating nociceptive pain (resulting from irritation, not damage to the nerves) and central deafferentation pain (related to central nervous system damage from a stroke or spinal cord injury); and
A psychologic screen has been performed and shows no evidence of a co-existing mental health condition which would significantly influence the perception of pain or would likely compromise the success of spinal cord stimulation treatment; and
No untreated substance use disorder exists; and
All facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment, and follow-up of the individual are available.

Dorsal root ganglion neurostimulation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

63650

63655

63685

63688

95970

95971

95972

Permanent implantation of a dorsal root ganglion neurostimulator is considered medically necessary for the treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies when performed according to policy guidelines and ALL of the following are met:

All criteria required for a short-term dorsal root ganglion stimulation trial has been met; and
The individual has reported ONE or more of the following during treatment with a temporarily implanted electrode
- Pain relief of at least 50%
- Functional improvement of at least 50% documented using a validated tool (e.g., Oswestry Disability Index [ODI], Brief Pain Inventory [BPI], Patient-Reported Outcomes Measurement Information System [PROMIS-29], etc.)
- Opioid use reduction of at least 50%

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Revision or removal of spinal cord stimulation or dorsal root ganglion stimulation components (e.g., electrodes, leads, pulse generator) is considered medically necessary for ONE or more of the following indications:

Lead fracture
Lead migration
Hardware malfunction confirmed by device interrogation showing abnormal impedance values, failure to communicate with generator, or loose connections
Loss of therapeutic stimulation coverage despite documented reprogramming attempts, with imaging confirmation of lead position
Device-related infection
Epidural hematoma or seroma
Cerebrospinal fluid leak
Skin breakdown or impending device extrusion
Pain over implant site refractory to conservative management
Allergic reaction to device components
Serious adverse events including autonomic neuropathy, prolonged monoparesis, neurologic injury, or other life-threatening complication

Revision or removal of spinal cord stimulation or dorsal root ganglion stimulation not meeting the criteria as indicated in this policy is considered not medically necessary.

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Replacement of a pulse generator or patient programmer is considered medically necessary for ONE or more of the following indications:

Device malfunction confirmed by device interrogation showing ONE or more of the following
- Abnormal impedance values outside manufacturer specifications
- Failure to deliver programmed stimulation parameters
- Communication failure between components
- Hardware failure not covered by active manufacturer warranty
End of battery life confirmed by device interrogation
Generator replacement required in conjunction with documented electrode array revision
Pulse generator replacement with advanced technology when there has been a significant clinical change as evidenced by ONE or more of the following
- New pain distribution requiring different stimulation coverage not achievable with current device and ALL of the following
  - Device interrogation and programming records demonstrate the inability to achieve therapeutic parameters despite comprehensive reprogramming attempts
  - The current device’s technical specifications (e.g., number of contacts, available waveforms, programming flexibility, spatial targeting capabilities) are insufficient to address the clinical change
- Development of MRI need requiring MRI-conditional device when current device is not MRI-conditional
- Documented loss of efficacy with current waveform despite optimal programming, with evidence supporting benefit from alternative waveform technology

Replacement of a pulse generator or patient programmer not meeting the criteria as indicated in this policy is considered not medically necessary.

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C1767	C1778	C1787	C1820	C1822	C1826	C1883
C1897	L8679	L8680	L8685	L8686	L8687	L8688

Professional Statements and Societal Positions Guidelines

American Society of Pain and Neuroscience – 2023

The American Society of Pain and Neuroscience best practices guideline for dorsal root ganglion stimulation, published in 2023, provides comprehensive evidence-based recommendations for the safe and efficacious application of DRG-S in chronic pain management. The guideline establishes evidence grades by indication, assigning Grade A (high certainty, Level I evidence) for CRPS I and II, Grade B (moderate certainty) for post-hernia repair pain, and Grade C (low certainty) for conditions including failed back surgery syndrome, post-joint surgery pain, peripheral neuropathy, and pelvic pain. The guideline emphasizes that DRG-S functions through distinct mechanisms compared to traditional spinal cord stimulation, including filtering of afferent signaling at the dorsal root ganglion, orthodromic propagation into the dorsal horn for multi-dermatomal coverage, and activation of low threshold mechanoreceptor fibers that utilize the endogenous opioid system. Unlike traditional SCS, DRG-S requires a fraction of the energy, can be delivered in a subthreshold paresthesia-free manner at frequencies as low as 4 Hz, and can be delivered intermittently.

The guideline provides specific recommendations for lead placement strategy based on pain type: for dermatomal neuropathic pain, leads should be placed at the affected dermatomal level; for multi-dermatomal neuropathic pain, strategic single lead placement (particularly at S1) can provide multi-dermatomal coverage through orthodromic propagation; and for mixed-pain syndromes, leads must be placed at each DRG innervating the pain source. Clinical outcomes demonstrate that DRG-S produces improvements not only in pain but also in function, mood, and quality of life, with pooled analysis showing a 63% responder rate (≥50% pain relief) at 12-month follow-up and particularly high success rates (80%) for groin and foot pain—areas historically challenging to treat with traditional SCS. The guideline serves as a comprehensive resource for standardizing DRG-S practice, ensuring that all interventional pain medicine fellows receive foundational training in patient selection, procedural techniques, and post-operative care based on current evidence and expert consensus.

American Society of Regional Anesthesia and Pain Medicine (ASRA-PM) and North American Neuromodulation Society - 2023

The American Society of Regional Anesthesia and Pain Medicine (ASRA-PM) and North American Neuromodulation Society multisociety consensus guideline on spinal cord stimulation, published in 2023, provides comprehensive evidence-based recommendations for patient selection and trial stimulation in chronic non-cancer pain. The guideline was developed through a modified Delphi method involving representatives from multiple professional organizations, achieving 100% consensus on 39 recommendations across seven sections. A trial of SCS should be performed prior to definitive implant for chronic low back and/or leg pain, complex regional pain syndrome, critical limb ischemia, and painful diabetic neuropathy (Grade B, moderate certainty), with the exception of chronic anginal pain in non-surgical candidates where a trial may not be necessary. All patients must be screened with an objective validated instrument for psychosocial factors, including depression (Grade B), performed by an independent psychologist specializing in chronic pain management.

The guideline establishes that trial success requires ≥50% pain relief on a validated scale (Grade A, high certainty), though in select cases where pain improvement is <50%, substantial functional improvement (≥50%) or significant opioid reduction (>50% decrease) may be considered successful on a case-by-case basis (Grade C, low certainty). Therapeutic efficacy should be evaluated multidimensionally using validated measures for pain relief, functional improvement, stable or decreased analgesic use, and overall satisfaction. paresthesia-based systems, the guideline recommends evaluating adequate paresthesia coverage with a threshold of ≥80% overlap with the painful area (Grade B). The guideline specifies that trial duration of more than 10 days is not ordinarily recommended due to higher infection risk and no clear advantages (Grade D, moderate certainty). These recommendations are intended to guide clinical practice while acknowledging that physicians should continue to make individualized judgments based on patient-specific considerations and preferences.

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G89.4	G89.21	G89.22	G89.28	G89.29	G90.50	G90.59
G90.511	G90.512	G90.513	G90.521	G90.522	G90.523	M25.511
M25.512	M25.521	M25.522	M25.531	M25.532	M25.541	M25.542
M25.551	M25.552	M25.561	M25.562	M25.571	M25.572	M54.6
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M54.17	M54.18	M54.31	M54.32	M54.41	M54.42	M54.50
M54.51	M54.59	M54.81	M54.89	M79.11	M79.12	M79.18
M79.601	M79.602	M79.604	M79.605	M79.609	M79.621	M79.622
M79.631	M79.632	M79.641	M79.642	M79.644	M79.645	M79.651
M79.652	M79.661	M79.662	M79.671	M79.672	M79.674	M79.675

Place of Service: Outpatient

Spinal cord stimulation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of insured business and, if elected, ASO.

Links

Link to Provider Resource Center for the Medical Policy Update

02/2024, New policies and guidelines published

Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

· Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats, other formats)

· Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.