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The 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 Code of Federal Regulations (CFR) Section 422.101.The rules say that Covered IndicationsSCS may be covered for the relief of chronic intractable pain under the following circumstances:To treat chronic pain caused by lumbosacral arachnoiditis that has not responded to medical management including physical therapy.(Presence of arachnoiditis is usually documented by presence of high levels of proteins in the Cerebrospinal Fluid (CSF) and/or by myelography or Magnetic Resonance Imaging (MRI)To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome).To treat intractable pain caused by complex regional pain syndrome I & II.To treat intractable pain caused by phantom limb syndrome that has not responded to medical management. To treat intractable pain caused by end-stage peripheral vascular disease, when the patient cannot undergo revascularization or when revascularization has failed to relieve painful symptoms and the pain has not responded to medical management.To treat intractable pain caused by post-herpetic neuralgia.To treat intractable pain caused by cauda equina injury.To treat intractable pain caused by incomplete spinal cord injury.To treat intractable pain caused by plexopathy.LimitationsSCS is considered experimental or investigational for all other indications including, but not limited to, treatment for refractory angina pectoris and treatment of cancer-related pain. There is insufficient evidence to conclude that SCS improves net health outcomes.Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. No payment may be made for the implantation of spinal cord (dorsal column) stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met:Patients being selected for a trial must not have current substance abuse;Patients must undergo proper patient education, discussion, and disclosure including an extensive discussion of the risks and benefits of this therapy; andOnly patients who experience a positive response to a trial should proceed to a 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. Please refer to CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual; Chapter 1, Part 2, Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation, Section 160.7 Electrical Nerve Stimulators for additional limitations. Percutaneous implantation of neurostimulator electrode array, epidural -Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime, in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, percutaneous implantation of neurostimulator electrode array, epidural can be covered more often in place of service ASC, outpatient hospital, or hospital.Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural -One permanent spinal cord stimulator per patient per lifetime performed in an ASC, outpatient hospital, or hospital. Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed and Revision Including Replacement, When Performed, of Spinal Neurostimulator Electrode Percutaneous Array(S), Including Fluoroscopy, When Performed will not be reimbursed in the office setting since they are included in Percutaneous Implantation of NeurostimulatorElectrode Array, Epidural. If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Generally, electronic analysis is not considered medically necessary when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.Relative Contraindication to SCS:The presence of other stimulation devices with sensing capacities (e.g., pacemakers or implantable cardiac defibrillators could be interfered by a spinal cord stimulator). This is a relative contraindication that may be covered when the patient has indications for a SCS and the documentation entails that the beneficiary was informed of their treatment options and explained the risks/benefits of SCS.Contraindications to SCS:Major psychiatric disorders, including somatization; No partial sparing of the dorsal column fibers (e.g., total paraplegia) of the treated area;Severe diseases likely to interfere with neuromodulation procedures (e.g., coagulopathies and immunodeficiency diseases);An active and untreated substance abuse disorder; Ongoing requirement for therapeutic diathermy; orSevere cognitive impairment rendering a patientincapable of giving informed consent for the procedure and/or operating the device.As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if itis reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.You can find this information in Medicare's Local Coverage Determination (LCD): Spinal Cord Stimulation for Chronic Pain (L36035).The rules say Indications and Limitations of CoverageTwo general classifications of electrical nerve stimulators are employed to treat chronic intractable pain: peripheral nerve stimulators and central nervous system stimulators.A. Implanted Peripheral Nerve StimulatorsPayment may be made under the prosthetic device benefit for implanted peripheral nerve stimulators. Use of this stimulator involves implantation of electrodes around a selected peripheral nerve. The stimulating electrode is connected by an insulated lead to a receiver unit which is implanted under the skin at a depth not greater than 1/2 inch.Stimulation is induced by a generator connected to an antenna unit which is attached to the skin surface over the receiver unit. Implantation of electrodes requires surgery and usually necessitates an operating room.NOTE: Peripheral nerve stimulators may also be employed to assess a patient's suitability for continued treatment with an electric nerve stimulator. As explained in 160.7.1, such use of the stimulator is covered as part of the total diagnostic service furnished to the beneficiary rather than as a prosthesis.B. Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators)The implantation of central nervous system stimulators may be covered as therapies for the relief of chronic intractable pain, subject to the following conditions:1. Types of ImplantationsThere are two types of implantations covered by this instruction:Dorsal Column (Spinal Cord) Neurostimulation -The surgical implantation of neurostimulator electrodes within the dura mater (endodural) or the percutaneous insertion of electrodes in the epidural spaceis covered.Depth Brain Neurostimulation -The stereotactic implantation of electrodes in the deep brain (e.g., thalamus and periaqueductal gray matter) is covered.2. Conditions for CoverageNo payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions listed below have been met:The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain;With respect to item a, other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the givenpatient;Patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation);All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow up of the patient (including that required to satisfy item c) must be available; andDemonstration of pain relief with a temporarily implanted electrode precedes permanent implantation.You can find this information in Medicare's National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.