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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 Indications and Limitations of Coverage

Two 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 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.

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 Implantations

There 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 space is 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 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.

Medicare Administrative Contractors may find it helpful to work with Quality Improvement Organizations to 
obtain the information needed to apply these conditions to claims.

You can find this information in Medicare's National Coverage Determination (NCD): Electrical Nerve 
Stimulators (160.7).

The rules say 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 patient's 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. In situations where the spinal cord stimulator has been working 
well but is in need of replacement for battery change, malfunction or end of stimulator life, a new trial is not 
needed to replace the stimulator. Selection of patients for implantation of spinal cord stimulators 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. Patients being selected for a trial

 Must not have active substance abuse issues.
 Must undergo proper patient education, discussion, and disclosure including an extensive discussion of the 
risks and benefits of this therapy.
 Must undergo appropriate psychological screening

Many experts recommend that the temporary neurostimulator be placed in an ASC or outpatient hospital 
setting. However, the temporary neurostimulator trial can be done in an office setting if all the sterility, 
equipment, professional training and support personnel required for the proper surgery, and follow up of the 
patient are available. Permanent neurostimulators must be placed in an ASC or hospital. Physicians performing 
SCS trials in the office setting must have like privileges at a local hospital or ASC, or the providers must be 
subspecialty boarded in Pain Medicine by the American Board of Anesthesiology.

It is preferable that physicians performing the SCS trial will also perform the permanent implant. If the 
physician implanting the trial neurostimulator does not or cannot implant the permanent neurostimulator, the 
patient should be informed of this in writing and given the name of the referral surgeon who will implant the 
permanent neurostimulator(s). It is expected that accurate patient selection will lead to most patients going on 
to receive permanent implants. 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 1-2 week trial). Physician judgment and experience will also be taken into 
account. Physicians with a low trial to permanent implant ratio (less than 50%) 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. Noridian will reimburse for 
placement of a maximum of 2 leads or 16 "contacts," and for 2 SCS trials per anatomic spinal region per 
patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different 
modalities of stimulation, including new technology). More than 2 SCS trials per anatomic spinal region per 
patient per lifetime is not considered reasonable and necessary. If a trial fails, a repeat trial is not appropriate 
unless there are extenuating circumstances that lead to trial failure. You can find this information in Medicare's 
Local Coverage Determination (LCD): Spinal Cord Stimulators for Chronic Pain (L36204).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.co