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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 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 Peripheral nerve blocks will be considered medically reasonable and necessary for normally 
temporary conditions such as the following diagnostic and therapeutic purposes: 
 
1. When the patients pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies 
have failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify 
the situation but this is only for diagnostic purposes and not long term treatment. 
2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain 
syndrome. 
3. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical 
picture is unclear but this is only for diagnostic purposes and not long term treatment. 
4. When an occipital nerve block is used to confirm the clinical impression of the presence of occipital 
neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as 
the result of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or 
bilateral, constant or intermittent. Nerve injury secondary to localized head trauma or trauma to the 
nerve from a scalp laceration can also cause this condition. Most commonly it is caused by an 
entrapment of the occipital nerve in its course from its origin from the C2 nerve root to its entrance into 
the scalp through the mid portion of the superior nuchal line. Blockage of the occipital nerve can 
confirm the clinical impression of occipital neuralgia particularly if the clinical picture is not entirely 
typical. If only temporary relief of symptoms is obtained, neurolysis of the greater occipital nerve may 
be considered via multiple techniques including radiofrequency and cryoanalgesia. In addition, the 
lesser and third occipital nerves can be involved in the pathology of headaches, and can be treated in a 
similar manner. 
 5. When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the 
nerve. Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a 
syndrome of pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When 
the history and examination point to the diagnosis, a suprascapular nerve block leading to relief of pain 
can confirm it. This may be followed by injection of depository steroids that sometime provide lasting 
relief. 
6. When the trigeminal nerve is blocked centrally at the trigeminal ganglion, or along one of the three 
divisions or at one of the many peripheral terminal branches (i.e., supraorbital nerve). 
7. Nerve blocks as preemptive analgesia 
 
You can find this rule in the Local Coverage Determination for Peripheral Nerve Blocks, L36850.  
 
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.