CPT 63685 · SCS · Premera Blue Cross
SCS — Permanent Implant (IPG) at Premera Blue Cross.
How Premera Blue Cross approaches CPT 63685 (SCS — Permanent Implant (IPG)) for prior-authorization review: at last review on 2026-03-01, the policy covers this code with prior authorization required.
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Coverage
Covered
Prior auth
Prior auth required
Last reviewed
2026-03-01
Policy number
7.01.546Criteria summary
High-level themes from the Premera Blue Cross policy of record for CPT 63685. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 26 weeks of conservative care typically required.
- Imaging concordance documentation required.
- Prior Successful trial 63650 documentation required (typically with ≥50% relief).
Source: Premera Medical Policy 7.01.546 — Spinal Cord and Dorsal Root Ganglion Stimulation
See the full Premera Blue Cross criteria.
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