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Cigna Healthcare (Commercial) · spinal cord stimulation

v1verified 2026-07-24pending changemanual-pull source

✓ conditional · commercial

Pending change: A future-dated CMM-211 (eff 2026-08-04, reported via ASIPP/secondary) is expected to ADD painful diabetic neuropathy as covered (gates unverified). Re-pull on/after 2026-08-04.

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Failed back surgery syndrome (FBSS)
      • criteria:
        • pain: intractable neuropathic leg pain after prior same-region spine surgery; surgery not indicated/declined
        • waveform: HF10/high-frequency allowed ONLY for this indication
      • name: CRPS / RSD — extremities only
      • criteria:
        • ref: Budapest-style criteria
        • excludes: head/face/neck, trunk, pelvis/perineum, viscera
        • surgery: not indicated
      • name: Chronic critical limb ischemia (CLI)
      • criteria:
        • not reconstruction candidate: vascular-surgeon attestation
        • grade: Rutherford II Cat 4 (ankle <40 mmHg, toe <30 mmHg)
        • imaging: angio/CT/MR multilevel disease
      • name: Chronic stable angina / myocardial ischemia
      • criteria:
        • class: CCS III/IV
        • attestation: cardiologist — CAD, not a revascularization candidate
        • failed: optimal medical therapy (antiplatelet + statin + anti-anginal + anti-HTN)
  • investigational:
    • DRG stimulation — initial placement for ALL indications (replacement of an existing DRG device only)
    • burst stimulation, and any generator mode other than tonic-low or high-frequency
    • high-frequency/HF10 for any indication other than FBSS
    • peripheral nerve stimulation / peripheral nerve field stimulation
    • diabetic / peripheral neuropathy (see pending_change), post-amputation/phantom limb, post-herpetic neuralgia, SCI dysesthesias, visceral/pelvic pain
    • radiculopathy or axial pain WITHOUT prior spinal surgery; failed cervical/thoracic surgery with arm/trunk pain
Conservative care
  • required: yes
  • min duration months: 6
  • satisfied by:
    • failed >=6 months supervised management (FBSS/CRPS)
    • condition-specific failed therapy (CLI/angina)
    • contraindicated
  • modalities named:
    • pharmacotherapy
    • physical therapy
    • CBT
    • activity/lifestyle modification
Trial
  • required: yes
  • min duration days: 2
  • success criteria:
    • logic: pain_reduction (>=50%) for FBSS/CRPS/CLI; beneficial clinical response for angina
    • pain reduction pct: 50
  • threshold is binding: yes
Psychological evaluation
  • required: yes
  • must clear: yes
  • note posture: behavioral-health attestation obtained pre-trial-authorization (no inadequately controlled MH/substance condition); pending/referred NOT sufficient
Quantity limits
  • applies: yes
  • repeat trial: a failed initial trial -> repeat trial NOT medically necessary
  • replacement: device malfunctioning/unrepairable/out-of-warranty or array revision; replacing functioning non-HF with HF not covered
Device / waveformrestricted
Payor-specific notes

Cigna delegates SCS/DRG to the eviCore guideline CMM-211 (V1.0.2025; re-published 2026-02-25 with no clinical changes). Distinctive vs the other commercial books: Cigna COVERS critical limb ischemia and chronic stable angina (which Aetna/UHC/Anthem treat as investigational), but deems initial DRG stimulation, ALL burst stimulation, PNS/PNfS, and (currently) diabetic/peripheral neuropathy NOT medically necessary, and confines HF10 to FBSS. Binding gates: >=6-month supervised conservative care (FBSS/CRPS), a behavioral-health attestation BEFORE trial authorization (not pending), and a binding trial (>48 hours + >=50% pain reduction; angina = beneficial response). CRPS is extremity-only. Source = actual fetched eviCore PDF (high confidence). PENDING: a 2026-08-04 revision is expected to add painful diabetic neuropathy — re-pull on/after that date.

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 a Cigna CMM-211 (eviCore) condition.

.SCSTRIALCIGNA
.SCSTRIALCIGNA

Assessment: *** — covered indication (select one): FBSS (intractable neuropathic leg pain
after prior same-region spine surgery, with further surgery not indicated or declined) |
CRPS / RSD of an extremity only (Budapest-style criteria, surgery not indicated; head,
face, neck, trunk, pelvis, perineum, and viscera are excluded) | chronic critical limb
ischemia at Rutherford II category 4 (ankle <40 mmHg / toe <30 mmHg, multilevel disease on
angio/CT/MR, with vascular-surgeon attestation that the patient is not a reconstruction
candidate) | chronic stable angina CCS III/IV (cardiologist attestation of CAD, not a
revascularization candidate, having failed optimal medical therapy — antiplatelet, statin,
anti-anginal, and anti-hypertensive).

Medical necessity per Cigna CMM-211 (eviCore, Spinal Cord and Dorsal Root Ganglion
Stimulation): for FBSS and CRPS, the patient has failed >=6 consecutive months of
supervised conservative management — pharmacotherapy, physical therapy, CBT, and
activity/lifestyle modification — or these were contraindicated: *** ; critical limb
ischemia and angina instead satisfy the condition-specific failed-therapy gates documented
in the indication above. Behavioral-health attestation was obtained before trial
authorization, with no inadequately controlled mental-health or substance-use condition.

Plan: Percutaneous SCS trial of >48 hours using a tonic-low or high-frequency waveform
(high-frequency/HF10 restricted to FBSS; burst not covered). Permanent implantation
requires >=50% pain reduction during the trial, or for angina a documented beneficial
clinical response. Risks, benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (enumerated; uniquely covers critical limb ischemia + chronic stable angina; CRPS extremity-only)
  • psych-eval line (behavioral-health attestation obtained pre-trial-authorization; pending/referred not accepted)
  • conservative-care line (>=6-mo supervised floor for FBSS/CRPS; condition-specific gates for CLI/angina)
  • trial line (binding >48-h / >=50% gate; angina = beneficial response; no repeat trial after failure)
  • device-waveform line (tonic-low or high-frequency only; HF10 FBSS-only; burst not covered)

Cautions

  • [!] Pending change: a CMM-211 successor effective 2026-08-04 is expected to ADD painful diabetic neuropathy as covered (gates unverified) — re-verify on/after that date. Trial-success gate is binding, and a failed initial trial makes a REPEAT trial not medically necessary — do not re-request a trial after a documented failure. Not covered (not medically necessary per CMM-211): initial DRG placement (all indications), burst stimulation and any generator mode other than tonic-low or high-frequency, HF10 outside FBSS, PNS/PNfS, diabetic/peripheral neuropathy (currently — see pending change), post-amputation/phantom limb, post-herpetic neuralgia, SCI dysesthesias, visceral/pelvic pain, radiculopathy or axial pain without prior spinal surgery. Regenerate if `cigna-commercial-scs.md` `version` advances past `source_version` above.

Prior-auth pathway

  • required: yes
  • pathway: eviCore / Evernorth prior authorization

Provenance

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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 Cigna Commercial SCS cell (eviCore CMM-211) 97676c3eff