The member must meet all of the following criteria:.Last resort treatment of moderate to severe (5 or more on a 10-point VAS scale) chronic neuropathic pain of certain origins (i.e., lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy (including diabetic peripheral neuropathy), post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy) that has been present for 12 or more months and.Inoperable chronic ischemic limb pain secondary to peripheral vascular disease or.Complex regional pain syndrome (CRPS) (also known as reflex sympathetic dystrophy ) Note: For clinical diagnostic criteria, see Appendix for the Budapest Criteria for Complex Regional Pain Syndrome or.Failed back surgery syndrome (FBSS) with low back pain and significant radicular pain or.This Clinical Policy Bulletin addresses spinal cord stimulation.Īetna considers the following interventions medically necessary:Ī trial of percutaneous dorsal column stimulation to predict whether a dorsal column stimulator will induce significant pain relief in members with chronic pain due to any of the following indications (1 through 4) when the criteria (5) listed below are met: Number: 0194 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References