Appeal type: unknown
Decision: unknown

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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that dorsal column stimulators may be covered as therapies 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 plexopathy. 
    To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and 
 nerve blocks. 
    To treat intractable pain caused by cauda equina injury. 
    To treat intractable pain caused by incomplete spinal cord injury. 
 
You can find this information in the Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal 
Column Stimulation) (L35450). 
 
The rules say that no 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 given patient; 
     
 
 
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; and 
    
Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this information in the 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.