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Medicare (Traditional Part A & B) · dorsal root ganglion stimulation

v1verified 2026-07-24

✓ conditional · medicare ncd

Criteria checklist

0 of 7 ticked
Indications
  • enumerated: no
  • description: Chronic intractable pain treated by central-nervous-system (dorsal column / spinal) neurostimulation. In practice DRG stimulation is FDA-labeled and used for CRPS type I/II (causalgia / RSD) of the LOWER EXTREMITIES — narrower than SCS; document the CRPS diagnosis and the distribution. Coverage conditions are the NCD 160.7-B set (identical to SCS).
Conservative care
  • required: yes
  • satisfied by:
    • tried and unsatisfactory
    • judged unsuitable or contraindicated
  • modalities named:
    • pharmacologic
    • surgical
    • physical
    • psychological
  • min duration months: not stated in the policy
Trial
  • required: yes
  • min duration days: not stated in the policy
  • success criteria:
    • logic: (pain_reduction OR med_reduction) AND functional_improvement
    • pain reduction pct: 50
    • med reduction pct: 50
    • functional improvement: required
  • threshold is binding: no
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: ordered at trial; pending; patient referred; result routed to authorization
Screening
  • multidisciplinary team: required
  • late or last resort: yes
Quantity limits
  • applies: no
Device / waveformagnostic
Payor-specific notes

DRG stimulation shares NCD 160.7 AND CPT 63650/63685/63688 with SCS but is a DISTINCT grid cell (per ROADMAP). Coverage conditions are the NCD 160.7-B central-nervous-system-stimulator set, identical to the SCS cell: late resort, conservative measures tried/unsuitable, multidisciplinary + psychological screening, and a successful temporary-electrode trial before permanent implant. The practical divergence is the INDICATION: DRG is FDA-labeled for CRPS I/II of the lower limbs, so the diagnosis line is narrower than SCS. The >=50% trial standard derives from the Noridian/Palmetto SCS LCDs (documented though not NCD-binding here). Trial is the gate; a successful trial leads to implant (templated separately).

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Same NCD 160.7-B gate as SCS; the only change is a CRPS-narrowed diagnosis line.

.DRGTRIALMCARE
.DRGTRIALMCARE

Assessment: *** — CRPS type I/II (causalgia / RSD) of the *** lower extremity, chronic
intractable neuropathic pain present *** , meeting clinical criteria (Budapest where
applicable).

Medical necessity per Medicare NCD 160.7 (Electrical Nerve Stimulators, Sec. B): this
patient has been managed with pharmacologic therapy, physical therapy, and interventional
treatment including sympathetic blocks where appropriate — *** — with unsatisfactory
response, or these measures were contraindicated. DRG stimulation is pursued as a
late-resort therapy. Multidisciplinary screening is complete; psychological evaluation was
ordered at the time of trial, the patient has been referred, and the result is pending and
will be forwarded to authorization. History, imaging, and screening documentation are on
file.

Plan: Percutaneous DRG stimulation trial. Trial response — targeting >=50% reduction in
target pain and/or >=50% reduction in analgesic use with functional improvement — will be
assessed and documented to support permanent implantation. Risks, benefits, and
alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (CRPS I/II lower-limb)

Cautions

  • Indication is narrower than SCS (DRG is FDA-labeled for CRPS I/II of the lower limbs). The >=50% figure derives from peer LCDs, not NCD text (`threshold_is_binding: false`); NCD 160.7 sets no pain-duration floor — document actual duration, don't assert a fabricated ">6 mo" gate. Regenerate if `medicare-in-ky-drg.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: OPD prior-auth list — implanted spinal neurostimulators (hospital outpatient)

Provenance

  • authority:
    • type: ncd
    • id: 160.7
    • title: Electrical Nerve Stimulators
    • section: B — Central Nervous System Stimulators (Dorsal Column)
    • applies because: DRG stimulation is epidural spinal neurostimulation governed by NCD 160.7-B; WPS (J8) and CGS (J15) publish no DRG-specific LCD
    • excluded:
      • DRG/SCS LCDs of other jurisdictions are not applicable to IN/KY
  • source: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=240
  • effective: 1995-08-07 · payor last reviewed: 2023-08-17 · we verified: 2026-07-24 · v1

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Change history

  • 2026-07-24drg/medicare: verified vs NCD 160.7-B text (MCP) - no change; last_verified 2026-07-24 77a5462ac5
  • 2026-06-28Add DRG stimulation x Medicare IN/KY cell (NCD 160.7-B) 6b2d8ca080