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Aetna (Commercial) · spinal cord stimulation

v2verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 8 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Failed back surgery syndrome (FBSS)
      • requires:
        • low back pain
        • significant radicular pain
      • name: CRPS I/II (RSD / causalgia)
      • ref: Budapest Criteria
      • name: Inoperable chronic ischemic limb pain (peripheral vascular disease)
      • name: Chronic neuropathic pain — specified origins (last resort)
      • origins:
        • lumbosacral arachnoiditis
        • phantom limb/stump
        • peripheral neuropathy (incl. diabetic peripheral neuropathy)
        • post-herpetic neuralgia
        • intercostal neuralgia
        • cauda equina injury
        • incomplete SCI
        • plexopathy
      • criteria:
        • vas min: 5
        • pain present months: 12
        • framing: last resort
      • name: Intractable angina (DCS as DME) — not a surgical candidate
      • criteria:
        • cad: angiographically documented significant CAD; not a candidate for CABG or PTCA
        • pharmacotherapy: >=1 month optimal (max tolerated doses of >=2 of: long-acting nitrates, beta-blockers, calcium-channel antagonists)
        • nyha class:
          • III
          • IV
        • reversible ischemia: documented by symptom-limited treadmill exercise test
        • trial: >=50% pain reduction with a 3-7 day percutaneous trial
  • investigational:
    • replacing a FUNCTIONING standard DCS with HF/burst/DTM (waveform upgrade of a working device); battery change for paresthesia on a working device
    • repeat trial after a failed trial, absent extenuating circumstances (lead migration, infection, anatomic difficulty)
    • cervical DCS (any non-CRPS indication)
    • DCS + DRG combined
    • concurrent two DCS
    • intra-op MEP/SSEP monitoring
    • chronic malignant pain; pelvic/visceral pain; coccydynia; gastroparesis; IBS
Documented pathology (objective basis)required
Conservative care
  • required: yes
  • min duration months: 6
  • min classes: 3
  • classes:
    • NSAIDs
    • TCAs
    • SSRIs
    • SNRIs
    • muscle relaxants (tizanidine/cyclobenzaprine/baclofen)
    • anticonvulsants
  • also requires:
    • formal IN-PERSON physical therapy with a licensed PT >=6 weeks within the past year (not virtual)
    • psychological therapies
Trial
  • required: yes
  • min duration days:
    • 3
    • 7
  • success criteria:
    • pain reduction pct: 50
    • functional improvement: implied
  • threshold is binding: yes
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: clearance obtained from a psychiatrist/psychologist/qualified MH professional (e.g., LCSW) pre-authorization
  • substance use exclusion: no untreated substance use disorder (ASAM)
Quantity limits
  • applies: yes
  • trial: <=16 contacts / 2 perc leads / 1 paddle
  • implant: additional <=16 contacts / 2 perc leads / 1 paddle
Replacement
  • covered when: positive prior DCS response AND manufacturer interrogation documents IPG 'end of life' or unrepairable
  • waveform upgrade of working device: not_covered
Device / waveformagnostic
Payor-specific notes

Aetna is not the dominant commercial book in IN/KY (Anthem/Elevance is), but this cell is now fully source-verified against the LIVE current CPB 0194 (Last Review 2026-05-21), pulled via the in-session browser 2026-07-24 (the Incapsula bot-gate passed). The 2026 version is materially stricter than the 2019 cache the cell was seeded from: a completed multidisciplinary work-up is required — >=6 months of failed conservative care (>=3 medication classes AND in-person PT >=6 weeks in the past year AND psychological therapies), psychological CLEARANCE pre-auth, no untreated substance use disorder (ASAM), an ODI functional score >=21%, advanced thoracic CT/MRI showing no lead-placement contraindication, all other pain sources ruled out (FBSS additionally requires imaging proof of the prior surgery), and a successful 3-7 day, >=50% trial. Covered indications: FBSS, CRPS I/II (Budapest), inoperable chronic ischemic limb pain, last-resort neuropathic pain of specified origins (VAS>=5, present >=12 months), and intractable angina (DCS as DME). HF (Senza), burst (BurstDR), and DTM (Medtronic) are equal to standard DCS; upgrading a WORKING device is not covered.

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

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Every clinical assertion maps to an Aetna CPB 0194 condition (current 2026-05-21 review).

.SCSTRIALAETNA
.SCSTRIALAETNA

Assessment: *** — covered indication (select one): FBSS with low back pain AND significant
radicular pain | CRPS I/II (Budapest criteria) | inoperable chronic ischemic limb pain from
peripheral vascular disease | chronic neuropathic pain of specified origin (lumbosacral
arachnoiditis / phantom limb-stump / peripheral neuropathy incl. diabetic / post-herpetic
neuralgia / intercostal neuralgia / cauda equina injury / incomplete SCI / plexopathy),
which for this class alone additionally requires VAS ***/10 (>=5), pain present >=12
months, and SCS pursued as a last resort | intractable angina (separate angina criteria
set).

Medical necessity per Aetna CPB 0194 (Spinal Cord Stimulation): conservative care has been
tried and has failed over >=6 months — *** — comprising at least three medication classes
(NSAIDs / TCAs / SSRIs / SNRIs / muscle relaxants / anticonvulsants), formal in-person
physical therapy with a licensed PT for >=6 weeks within the past year, and psychological
therapies. Pre-procedure psychological clearance was obtained from *** (psychiatrist /
psychologist / LCSW) before authorization, and there is no untreated substance use disorder
by ASAM criteria. Functional disability is documented at an Oswestry Disability Index of
***% (>=21%). Thoracic CT/MRI *** shows no anatomic contraindication to lead placement and
all other reasonable sources of pain have been ruled out; where the indication is FBSS, the
imaging demonstrates the prior surgery. Any prior spinal surgery is >=6 months out.

Plan: Percutaneous SCS trial of 3-7 days, with trial hardware within the covered cap
(<=16 contacts / 2 percutaneous leads / 1 paddle). Permanent implantation requires >=50%
reduction in target pain during the trial, documented by the trial placement and lead-pull
notes. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (enumerated indications incl. intractable angina; gated specified-neuropathic-origin class)
  • psych-eval line (clearance obtained pre-authorization, not pending)
  • conservative-care line (>=6-mo, >=3 med classes + in-person PT + psychological therapies — ALL indications)
  • functional + imaging gates (ODI >=21%, thoracic CT/MRI, other sources ruled out, FBSS prior-surgery imaging)
  • trial line (binding 3-7-day window; >=50% pain reduction only — no analgesic branch)

Cautions

  • Trial-success gate is BINDING and pain-reduction-only (>=50%); CPB 0194 records no analgesic-use branch — do not chart the Medicare-style "and/or analgesic reduction" framing on Aetna members. Conservative care is a >=6-month / >=3-class + PT + psych-therapy gate for ALL indications; the >=12-month figure is the neuropathic-pain DURATION requirement, not the conservative floor. HF (Senza) / burst (BurstDR) / DTM (Medtronic) equal standard DCS; upgrading a WORKING device is not covered. Regenerate if `aetna-commercial-scs.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes

Provenance

  • authority:
    • type: commercial_policy
    • id: Aetna CPB 0194
    • title: Spinal Cord Stimulation
    • supplements: NCD 160.7 / applicable LCDs (does not supersede)
  • source: https://www.aetna.com/cpb/medical/data/100_199/0194.html
  • effective: 1997-12-17 · payor last reviewed: 2026-05-21 · we verified: 2026-07-24 · v2

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Change history

  • 2026-07-24aetna/scs v2: CPB 0194 read LIVE via browser (Incapsula gate passed) at current 2026-05-21 review; the 2019-cache cell was materially out of date - corrected conservative floor 12mo->6mo + expanded med classes + in-person PT + psych therapies; ADDED ODI>=21%, thoracic CT/MRI + rule-out gates, FBSS prior-surgery imaging, intractable-angina indication, DTM waveform; needs_reverification cleared; dot phrase regenerated 9a1ed998bd
  • 2026-06-27Seed: locked schema + SCS templated for Medicare (NCD 160.7) and Aetna (CPB 0194) 89cec9dbfe