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 spinal cord stimulation blocks pain conduction pathways to the brain and may stimulate 
endorphins. The neurostimulator electrodes used for this purpose are implanted percutaneously in the epidural 
space through a special needle. Some patients may need an open procedure requiring laminectomy to place the 
electrodes. 
 
After placement of the electrodes, the patient is provided with an external neurostimulator, initially on a trial 
basis. The trial period may be extended up to four weeks. If during the trial period it is determined that the 
modality is not effective, or it is not acceptable to the patient, the electrodes may be removed. 
 
If the trial has been successful, a spinal neurostimulator and pulse generator are inserted subcutaneously and 
connected to the implanted electrodes. In some cases, the trial may be conducted using temporary electrodes. 
 
Covered Indications 
 
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. 
 
Limitations 
 
No payment may be made for the implantation of dorsal column stimulators or services and supplies related to 
such implantation, unless all of the conditions for coverage located in NCD 160.7 for Electrical Nerve 
Stimulators have been met. 
 
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
You can find these rules in the Local Coverage Determination (LCD) Spinal Cord Stimulation (Dorsal Column 
Stimulation) L35450. 
 
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.