Cigna Healthcare (Commercial) · dorsal root ganglion stimulation

v1verified 2026-07-24pending changemanual-pull source

✗ investigational / not covered · commercial

Pending change: CMM-211 successor effective 2026-08-04 (re-pull then)

Criteria checklist

0 of 6 ticked

Indications

enumerated: yes
covered:
- - name: DRG device REPLACEMENT only (of an existing DRG device — malfunction/out-of-warranty or array revision)
investigational:
- INITIAL DRG stimulation placement — not medically necessary for ALL indications
- replacing an SCS with a DRG device

Conservative care

required: not stated in the policy
min duration months: not stated in the policy
note: n/a — initial DRG not covered

Trial

required: not stated in the policy
min duration days: not stated in the policy
success criteria: not stated in the policy
threshold is binding: not stated in the policy

Psychological evaluation

required: not stated in the policy
must clear: not stated in the policy
note posture: n/a

Quantity limits

applies: yes
note: replacement of an existing DRG device only

Device / waveformnot_applicable

Payor-specific notes

Per eviCore CMM-211, Cigna deems INITIAL DRG stimulation NOT medically necessary for ALL indications (evidence considered insufficient / under investigation) — the opposite of Anthem and UHC, which cover DRG for CRPS. Only REPLACEMENT of an existing DRG device is covered; replacing an SCS with a DRG device is not covered. Derives from cigna-commercial-scs.md. PENDING: 2026-08-04 successor.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Cigna (eviCore CMM-211) deems **initial DRG stimulation not medically necessary for all indications.** There is no medical-necessity pathway for initial DRG placement.

.DRGCIGNA

This patient would be a candidate for dorsal root ganglion stimulation, but initial DRG
placement is not a covered benefit under this plan (Cigna CMM-211, eviCore: not medically
necessary for all indications). Where the indication fits, I will instead pursue
dorsal-column SCS (see .SCSTRIALCIGNA); otherwise the medical rationale for DRG is
documented here for appeal: *** . Replacement of an existing DRG device — malfunction,
out-of-warranty, or array revision — remains separately coverable.

Cautions

[!] 2026-08-04 successor pending — re-check whether initial DRG coverage changes. Regenerate if `cigna-commercial-drg.md` `version` advances.

Prior-auth pathway

required: yes
pathway: eviCore / Evernorth

Provenance

authority:
- type: commercial_policy
- id: Cigna eviCore CMM-211
- title: Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211)
- delegated by: Cigna (authored by eviCore / Evernorth)
- applies because: Cigna's SCS/DRG guideline (CMM-211) governs DRG
source: https://www.evicore.com/sites/default/files/clinical-guidelines/2025-03/Cigna_Spinal%20Cord%20and%20Dorsal%20Root%20Ganglion%20Stimulation%20(CMM-211)_FINAL_V1.0.2025_pub03.19.2025.pdf
archived copy: sources/evicore_cmm211-scs-drg_2025-07-01.pdf (sha256 bce7ba45f04f… — kept in the content repo, not served here)
effective: 2025-07-01 · payor last reviewed: 2026-02-25 · we verified: 2026-07-24 · v1

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Change history

2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
2026-06-28Add commercial DRG cells: Anthem, UHC, Cigna (from SCS-guideline data) 829db7c6dd