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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 for implanted Peripheral Nerve Stimulators, payment 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. 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. For 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 Implantations: There are two types of implantations covered by this instruction: Dorsal Column
(Spinal Cord), euro-stimulation or the surgical implantation of neurostimulator electrodes within the dura mater
(endodural) or the percutaneous insertion of electrodes in the epidural space is covered. Depth Brain Neurostimulation
or the stereotactic implantation of electrodes in the deep brain (e.g., thalamus and periaqueductal
gray matter) is covered.
2. Conditions for Coverage: 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 Medicare's National Coverage Determination (NCD): 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.