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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 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. 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 
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 rule at the Medicare Local Coverage Determination (LCD) L36204: Spinal Cord Stimulators 
for Chronic Pain. 
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.