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Dorsal Column Stimulator for Pain Management

Last Review Date: September 12, 2025 
Number: MG.MM.SU.19g

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A dorsal (spinal) column stimulator (DCS) is an electrical stimulation device for chronic pain control. The DCS unit is comprised of an electrode that is connected to a battery-powered electronic stimulus generator, which is surgically implanted in the back near the spinal cord. An electrical signal is transmitted to the spinal cord to decrease the sensation of pain, which is then replaced by a mild tingling sensation. The process involves a first step trial treatment whereby a temporary electrode is utilized and connected to a stimulus generator that is worn on the belt; the current may be switched on and off, or the intensity of the current changed. If good pain relief is achieved, then the entire system is implanted beneath the skin so that it is invisible.
Guideline Members are eligible for coverage of lumbar/thoracic DCS implantation as an in-patient procedure for one of the following indications:

1. Failed back surgery syndrome (FBSS) with primarily radicular pain
2. Inoperable chronic critical limb ischemia
3. Reflex sympathetic dystrophy (RSD)/complex regional pain syndrome (CRPS)

4. Diabetic peripheral neuropathy (e.g., Proclaim XR SCS System)
   Note: Dorsal root ganglion stimulators (e.g., Axium and Proclaim™ neurostimulator systems) are medically necessary for moderate-to-severe chronic intractable pain of the lower limbs in members with CRPS types I (formerly RSD) and II (causalgia)

   The following conditions must be met:

5. Use of DCS is limited to late or last resort for chronic intractable pain
6. Other methods of pain management have either failed or are contraindicated (e.g., pharmacological, surgical, physical or psychological therapies)
7. Further surgical intervention is contraindicated, or the member does not wish to proceed with spinal surgery
8. Member has been evaluated by a multi-disciplinary team inclusive of psychological as well as physical evaluation

5. Absence of any untreated existing drug addiction problems
6. Pain is predominantly neuropathic
7. Pain reduction is achieved with trial of percutaneous spinal stimulation; both:  Trial must last ≥ 2 days  Improved function and ≥ 50% reduction in pain must be demonstrated with temporarily implanted electrode prior to the permanent implantation Limitations/Exclusions
8. Lumbar/thoracic spinal cord stimulators are considered experimental/investigational for all conditions not listed above; including visceral or pelvic pain syndromes.

9. Cervical spinal cord stimulators are considered experimental/investigational for all indications due to a lack of strong peer-reviewed evidence supporting use.

   Revision History Oct. 10, 2025 Added dorsal root ganglion (DRG) stimulation as medically necessary for diabetic peripheral neuropathy and lower limb intractable chronic regional pain syndrome, and removed from Limitations/Exclusions Dec. 8, 2023 Added the Proclaim XR Spinal Cord Stimulation System as investigational Sept. 13, 2019 Added language communicating allowance of dorsal column stimulators for members not wishing to proceed with spinal surgery. Mar. 13, 2017 Communicated that dorsal root ganglion stimulation is not considered medically necessary. Nov. 13, 2015 Removed nonmalignant pain, angina and refractory neuropathic pain coverage terms to clarify that medical necessity is limited to failed back surgery syndrome, inoperable chronic critical limb ischemia and reflex sympathetic dystrophy (RSD)/complex regional pain syndrome (CRPS).

   Applicable Procedure Codes
   63650 Percutaneous implantation of neurostimulator electrode array, epidural

   63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
   63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
   63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
   63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
   63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming 95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

95972 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex spinal cord, or peripheral (ie, peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour 0282T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period 0283T Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; permanent, with implantation of a pulse generator 0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed 0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed L8680 Implantable neurostimulator electrode, each.
L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofrequency receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Applicable ICD-10 codes
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy G54.6 Phantom limb syndrome with pain G54.7 Phantom limb syndrome without pain G56.40 Causalgia of unspecified upper limb G56.41 Causalgia of right upper limb G56.42 Causalgia of left upper limb G56.80 Other specified mononeuropathies of unspecified upper limb G56.81 Other specified mononeuropathies of right upper limb G56.82 Other specified mononeuropathies of left upper limb G57.70 Causalgia of unspecified lower limb G57.71 Causalgia of right lower limb

G57.72 Causalgia of left lower limb G57.80 Other specified mononeuropathies of unspecified lower limb G57.81 Other specified mononeuropathies of right lower limb G57.82 Other specified mononeuropathies of left lower limb G58.8 Other specified mononeuropathies G90.50 Complex regional pain syndrome I, unspecified G90.511 Complex regional pain syndrome I of right upper limb G90.512 Complex regional pain syndrome I of left upper limb G90.513 Complex regional pain syndrome I of upper limb, bilateral G90.519 Complex regional pain syndrome I of unspecified upper limb G90.521 Complex regional pain syndrome I of right lower limb G90.522 Complex regional pain syndrome I of left lower limb G90.523 Complex regional pain syndrome I of lower limb, bilateral G90.529 Complex regional pain syndrome I of unspecified lower limb G90.59 Complex regional pain syndrome I of other specified site M54.15 Radiculopathy, thoracolumbar region M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M54.18 Radiculopathy, sacral and sacrococcygeal region M96.1 Postlaminectomy syndrome, not elsewhere classified

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