QualCare Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation prior authorization requirements (2026)
What QualCare generally requires to approve Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (CPT 63650, 63655, 63663, 63664, 63685, 63688, 63661), for commercial plans. Yes. QualCare generally requires prior authorization for Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (CPT 63650, 63655, 63663, 63664, 63685, 63688, 63661).
Medical-necessity criteria QualCare generally applies
Prior authorization (eviCore CMM-211 and/or Cigna direct). Cigna covers a short-term TRIAL of a dorsal-column spinal cord stimulator for chronic intractable pain from failed back syndrome or CRPS/RSD when there is failure of at least 6 consecutive months of physician-supervised conservative management, surgery is not indicated, and a mental-health evaluation finds no inadequately controlled psychiatric condition; a PERMANENT implant follows a successful trial. Governed by Cigna Medical Coverage Policy 0380 and eviCore CMM-211.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation. Confirm the covered diagnosis list against the current QualCare policy.
How to submit
- Method: eviCore portal
- Portal: eviCore by Evernorth (Cigna MSK/Spine)
Sources & verification
- BindingSource — Cigna Medical Coverage Policy 0380 — Spinal Cord / Dorsal Column Stimulation, with eviCore CMM-211 (0380).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 2026-06-26.
Frequently asked questions
Does QualCare require prior authorization for Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation?
Yes. QualCare generally requires prior authorization for Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation (CPT 63650, 63655, 63663, 63664, 63685, 63688, 63661).
What does QualCare require to approve Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation?
Prior authorization (eviCore CMM-211 and/or Cigna direct). Cigna covers a short-term TRIAL of a dorsal-column spinal cord stimulator for chronic intractable pain from failed back syndrome or CRPS/RSD when there is failure of at least 6 consecutive months of physician-supervised conservative management, surgery is not indicated, and a mental-health evaluation finds no inadequately controlled psychi… Always confirm against the current QualCare policy.
How long does a QualCare prior authorization take?
Turnaround varies by plan and submission method. Check the QualCare portal for current timeframes.
Submitting Dorsal Column (Lumbar) Neurostimulators: Trial or Implantation to QualCare?
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.