CPT 63685 · SCS · Wellpoint of New Jersey — NJ Medicaid
SCS — Permanent Implant (IPG) at Wellpoint of New Jersey — NJ Medicaid.
How Wellpoint of New Jersey — NJ Medicaid approaches CPT 63685 (SCS — Permanent Implant (IPG)) for prior-authorization review: at last review on 2026-05-06, the policy covers this code with prior authorization required.
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Carelon IPM (MSK01)Criteria summary
High-level themes from the Wellpoint of New Jersey — NJ Medicaid 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.
- Prior Successful percutaneous SCS trial (CPT 63650) documentation required (typically with ≥50% relief).
Source: Carelon Clinical Appropriateness Guidelines — Interventional Pain Management (SCS section)
See the full Wellpoint of New Jersey — NJ Medicaid criteria.
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