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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 no payment may be made for the implantation of dorsal column or deep brain stimulators or 
services and supplies related to such implantation, unless all of the conditions listed below have been met: 
 
A. The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
B. 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; 
C. 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); 
D. 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 
E. Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) - 
Effective August 7, 1995. 
 
The rules say that the implantation of spinal cord stimulators (SCS) may be covered as therapies for the relief 
of chronic intractable pain. SCS is best suited for neuropathic pain, but may have some limited value in other 
types of nociceptive severe, intractable pain. Therapy consists of a short trial with a percutaneous implantation 
of neurostimulator electrode(s) in the epidural space for assessing a patients suitability for ongoing treatment 
with a permanent surgically implanted nerve stimulator. Performance and documentation of an effective trial is 
a prerequisite for permanent nerve stimulation. You can find this rule in the Local Coverage Determination 
(LCD) - Spinal Cord Stimulators for Chronic Pain (L37632) - Effective May 13, 2021. 
 
The rules say that selection of patients for implantation of SCS is critical to success of this therapy. SCS 
therapy should be considered as a late option after more conservative attempts, such as medications, physical 
therapy, psychological therapy or other modalities have been tried. Patients must have undergone careful 
screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must 
include psychological, as well as, physical evaluation). Documentation of the history and careful screening 
must be available in the patient chart if requested. You can find this rule in the Local Coverage Determination 
(LCD) - Spinal Cord Stimulators for Chronic Pain (L37632) - Effective May 13, 2021. 
 The rules say that only 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 to 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%) may/can/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. Failure to provide this 
documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that 
all patients may not have a favorable result of the trial implant; but careful selection should find the most 
appropriate patients. You can find this rule in the Local Coverage Determination (LCD) - Spinal Cord 
Stimulators for Chronic Pain (L37632) - Effective May 13, 2021. 
 
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.