Appeal type: Surgery
Decision: Unfavorable

Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules state that it is expected that accurate patient selection will lead to most patients going on to receive permanent implants. Only patients who experience a positive response to a trial should proceed toa permanent implantation. All trials which proceed to permanent implant must have adequate documentation in the chart to support that decision. A successful trial should be associated with at least a 50% reduction of target pain, or 50% reduction of analgesic medications, and show some element of functional improvement. (Patients with reflex sympathetic dystrophy may show lower levels of improvement since it takes longer periods for improvement than the typical 1-2 week trial). Physician judgment and experience will also be taken into account.Physicians with a low trial to permanent implant ratio (less than 50%) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials.Noridian will reimburse for placement of a maximum of 2 leads or 16 "contacts," and for 2 SCS trials per anatomic spinal region per patient per lifetime (with exceptions allowed fortechnical limitations for the initial trials or for use of different modalities of stimulation, including new technology). More than 2 SCS trials per anatomic spinal region per patient per lifetime is not considered reasonable and necessary.If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. You can find these rules in Local Coverage Determination (LCD): Spinal Cord Stimulators for Chronic Pain (L35136).If you want to read theseMedicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  Explanation of decisionWe decided that the Plan does not have to pay fora repeatspinal cord stimulator trial.You asked the Plan to pay fora repeat spinal cord stimulator trial. You say that the enrollee's physician says this may help.The Plan denied your request. The Plan says the documentation does not show there are special circumstances as to why the first trial did not work.The Plan follows Medicare rules. Medicare rules say that if a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a repeat spinal cord stimulator trial. Our reviewer says that Medicare criteria have not been met. Our physician reviewer found the patient failed the SCS trial. There is no indication to repeat a failed trial. The requested procedure is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat spinal cord stimulator trial have not been met.Therefore, we decided that the Plan does not have to pay fora repeat spinal cord stimulator trial.