Is CPT 63650 (Implantation of neuroelectrodes) medically necessary for a patient with chronic pain syndrome (G89.4), lumbar radiculopathy, and chronic bilateral foot pain and neuropathy?

Medical Necessity Review: DRG Stimulator for Chronic Bilateral Foot Pain and Neuropathy

Based on the Aetna criteria and available clinical documentation, CPT 63650 (DRG stimulator trial) is NOT medically necessary for this patient at this time due to incomplete documentation of required criteria, specifically the absence of an Oswestry Disability Index (ODI) score and inadequate documentation of physical therapy duration.

Critical Missing Documentation

Oswestry Disability Index (ODI) Score - NOT MET

• The Aetna policy explicitly requires an ODI score ≥21% for spinal cord/DRG stimulator approval 1
• No ODI score is documented anywhere in the submitted clinical records
• This is a mandatory, non-negotiable requirement that cannot be waived or substituted with clinical impression
• Recommendation: Obtain and document ODI score before proceeding with authorization

Physical Therapy Documentation - UNCLEAR/INSUFFICIENT

• The policy requires "formal in-person physical therapy with a licensed physical therapist for a minimum of 6 weeks within the past year" 1
• Clinical notes state only that "physical therapy (no relief)" was tried, without specifying:
  • When PT was performed (must be within past year)
  • Duration of treatment (must be minimum 6 weeks)
  • Whether it was formal in-person therapy with a licensed therapist
  • Specific modalities attempted
• Recommendation: Obtain detailed PT records documenting dates, duration, frequency, and therapist credentials

Indication Analysis: Does This Meet DRG Stimulator Criteria?

Primary Indication: Chronic Neuropathic Foot Pain

• The patient's primary complaint is bilateral foot pain and neuropathy (rated 9/10), which she describes as worse than her back pain [@case documentation@]
• This potentially meets Aetna criterion A.4: "moderate to severe chronic neuropathic pain...peripheral neuropathy...present for 12 or more months" 1
• EMG/NCS from May 2025 confirms "sensory neuropathies bilaterally" and "moderate chronic LS and S1 radiculopathy" [@case documentation@]
• The American Society of Anesthesiologists supports neuromodulation for intractable peripheral neuropathic pain refractory to conservative management 1

Failed Back Surgery Syndrome (FBSS) - NOT MET

• FBSS criterion requires "significant radicular pain" as the primary complaint 1
• This patient's radicular leg pain actually improved >60% after bilateral L5-S1 TFESI [@case documentation@]
• Her current chief complaint is axial low back pain and foot neuropathy, not radicular pain
• FBSS indication does not apply to this case

Complex Regional Pain Syndrome (CRPS) - REQUIRES CLARIFICATION

• The Aetna policy specifically covers DRG stimulators for CRPS types I and II when general criteria are met 1
• Budapest Criteria assessment is incomplete in the documentation:
  • Sensory: Patient reports burning, sharp pain in feet - PRESENT
  • Vasomotor: No documentation of temperature asymmetry or skin color changes - NOT DOCUMENTED
  • Sudomotor/edema: Swelling noted on exam - PRESENT
  • Motor/trophic: Decreased ROM documented, surgical scars present - PRESENT
• The patient does NOT clearly meet Budapest Criteria as she lacks documented vasomotor signs and the pain is not "disproportionate to inciting event" (she has extensive foot surgery history) 1
• CRPS diagnosis cannot be confirmed from available documentation

Conservative Treatment Requirements - PARTIALLY MET

Medication Management - MET

• Patient has tried and failed multiple medication classes [@case documentation@]:
  • Gabapentin (caused numbness and dizziness)
  • Lyrica (caused swelling)
  • Cymbalta (caused swelling)
  • Currently on hydrocodone and previously Butrans patch
• This meets the requirement for trial of anticonvulsants and SNRIs 1

Psychological Evaluation - MET

• Behavioral assessment completed 9/15/25 by LCSW [@case documentation@]
• PHQ-9 score: 5 (mild depression)
• DASS-21: mild depression, normal anxiety and stress
• Opioid Risk Tool: 1 (low risk)
• LCSW attestation: "no significant psychological factors that would hinder success"
• This satisfies the requirement for clearance from qualified mental health professional 1

Substance Use Disorder Screening - MET

• NIDA assessment: no known addictions
• Opioid Risk Tool: low risk
• No evidence of untreated substance use disorder 1

Six-Month Post-Operative Requirement - MET

• Patient has "extensive surgical history" on feet with multiple prior surgeries [@case documentation@]
• All surgeries appear to be >6 months old based on chronicity of symptoms 1

Clinical Appropriateness Beyond Insurance Criteria

DRG Stimulation for S1 Distribution Pain

• The treating physician specifically recommends "S1 DRG stimulator trial" for bilateral foot pain and neuropathy [@case documentation@]
• DRG stimulation targets specific dermatomal distributions and is particularly effective for focal neuropathic pain 2
• The American Society of Anesthesiologists supports peripheral nerve stimulation for intractable peripheral neuropathic pain when conservative treatments fail 1, 2
• A trial should be performed before permanent implantation 1, 2

Neuroinflammation in Chronic Radiculopathy

• Recent evidence demonstrates elevated neuroinflammation markers in patients with chronic lumbar radiculopathy, correlating with clinical presentation 3
• This patient's EMG confirms chronic S1 radiculopathy bilaterally, supporting an inflammatory/neuropathic pain mechanism 3
• Neuromodulation may address this neuroinflammatory component when medications fail 3

Common Pitfalls and How to Avoid Them

Pitfall #1: Confusing Spinal Cord Stimulation with DRG Stimulation

• While both fall under CPT 63650, DRG stimulators have specific indications for focal dermatomal pain 1
• This patient's foot-predominant symptoms make DRG stimulation more appropriate than traditional dorsal column stimulation
• Ensure authorization request specifies DRG stimulation for S1 distribution

Pitfall #2: Inadequate Documentation of Conservative Treatment Failure

• Simply stating "PT failed" is insufficient 1
• Must document specific dates, duration (minimum 6 weeks), frequency, modalities, and therapist credentials
• Must be within the past year

Pitfall #3: Missing Functional Assessment

• ODI score is non-negotiable for Aetna approval 1
• Cannot substitute with clinical impression or pain scores
• Must be formally administered and documented

Required Actions Before Approval

1. Obtain and document ODI score - must be ≥21% 1
2. Obtain detailed PT records documenting:
   • Dates of treatment (must be within past year)
   • Duration (minimum 6 weeks)
   • Frequency of sessions
   • Licensed therapist credentials
   • Specific modalities attempted
   • Reason for discontinuation/failure 1
3. Consider formal CRPS evaluation if pursuing that indication, though peripheral neuropathy indication appears more appropriate 1

Final Determination

CPT 63650 is NOT medically necessary at this time due to incomplete documentation. The patient appears to be an appropriate clinical candidate for DRG stimulation based on chronic intractable bilateral foot neuropathy refractory to multiple medication trials, but mandatory documentation requirements (ODI score and detailed PT records) must be completed before authorization can be granted 1. Once these items are provided and meet threshold requirements, the procedure would be medically appropriate under Aetna criterion A.4 for chronic peripheral neuropathy 1.