Medicare (CMS LCD/NCD) DRG Stimulation (Dorsal Root Ganglion) prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve DRG Stimulation (Dorsal Root Ganglion) (CPT 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970, 95971), for Medicare (NY) plans. Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for DRG Stimulation (Dorsal Root Ganglion) (CPT 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970, 95971).
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Dorsal root ganglion stimulation is adjudicated under the same authority as spinal cord stimulation: NCD 160.7 (Electrical Nerve Stimulators), with NO New York LCD in force (Wellpoint Federal publishes no SCS/DRG local coverage determination). Coverage requires chronic intractable pain treated as a LATE resort after pharmacologic, surgical, physical and psychological modalities have failed or been judged unsuitable, a documented psychological evaluation, and a successful trial before permanent implantation. DRG stimulation is FDA-approved specifically for complex regional pain syndrome type I/II of the lower extremities, so the indication documented should match that approved use; off-indication use invites denial as not reasonable and necessary. Billing shares the SCS code family (63650, 63655, 63661-63664, 63685, 63688) with programming 95970-95971; fluoroscopic guidance is bundled into 63650 and is not separately billable. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Documentation of CRPS type I or II of the lower extremity (or a clearly justified alternative indication)
- failed or contraindicated prior modalities
- psychological evaluation
- trial stimulation results with percent relief and functional change.
How to submit
- Method: HOSPITAL OUTPATIENT DEPARTMENT: implanted spinal neurostimulators require CMS OPD prior authorization (since 07/01/2021); standard decision 7 calendar days. Office/ASC: no Part B prior authorization; bill with documentation on file.
Sources & verification
- BindingSource — NCD 160.7 - Electrical Nerve Stimulators (governs DRG stimulation absent a NY LCD) (160.7).View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-08-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for DRG Stimulation (Dorsal Root Ganglion)?
Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for DRG Stimulation (Dorsal Root Ganglion) (CPT 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 95970, 95971).
What does Medicare (CMS LCD/NCD) require to approve DRG Stimulation (Dorsal Root Ganglion)?
Dorsal root ganglion stimulation is adjudicated under the same authority as spinal cord stimulation: NCD 160.7 (Electrical Nerve Stimulators), with NO New York LCD in force (Wellpoint Federal publishes no SCS/DRG local coverage determination). Coverage requires chronic intractable pain treated as a LATE resort after pharmacologic, surgical, physical and psychological modalities have failed or been… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting DRG Stimulation (Dorsal Root Ganglion) to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.