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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 state that dorsal column stimulators may be covered as therapies for the relief of chronic intractable
pain under the following circumstances:
1. 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]).
2. To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of
post-laminectomy syndrome (failed back syndrome).
3. To treat intractable pain caused by complex regional pain syndrome I & II.
4. To treat intractable pain caused by phantom limb syndrome that has not responded to medical
management.
5. 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.
6. To treat intractable pain caused by post-herpetic neuralgia.
7. To treat intractable pain caused by plexopathy.
8. To treat intractable pain caused by intercostal neuralgia that did not respond to medical management and
nerve blocks.
9. To treat intractable pain caused by cauda equina injury.
10. 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.
You can find this in the Local Coverage Determination (LCD): Spinal Cord Stimulation (Dorsal Column
Stimulation) (L35450).
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 in the National Coverage Determination (NCD) for 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.