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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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for
Medicare & Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.1.

The rules state that 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. 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 the Medicare National Coverage Determination (NCD)
Electrical Nerve Stimulators (160.7 and 160.7.1).

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.