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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 peripheral nerve stimulation (PNS) may be covered for relief of chronic intractable pain for 
patients with conditions known to be responsive to this form of therapy, and only after attempts to cure the 
underlying conditions and appropriate attempts at medication management, physical therapy, psychological 
therapy and other less invasive interventional treatments. As with spinal nerve stimulations (spinal cord 
stimulators (SCS) are dealt with in a companion policy), severe neuropathic pain is typically well suited for 
successful responses to PNS. There may be rare, selected situations where both spinal cord stimulators and 
peripheral neurostimulators are used together. 
 
PNS refers to the placement of a lead by a physician (via open surgical or percutaneous approach) near the 
known anatomic location of a peripheral nerve. Peripheral nerve field stimulation (PNFS) refers to use of a lead 
placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral 
nerve). In both PNS and PNFS leads are composed of multiple contacts (of varying number) connected to an 
external pulse generator when temporary and implanted when made permanent. 
 
PNS, like deep brain stimulation and spinal cord stimulation modulates the nervous system with electrical 
stimulation to lessen chronic pain and other conditions. PNFS has an uncertain mechanism of action. 
 
PNS has been tried for over 50 years and has been used in a wide variety of chronic pain syndromes, but the 
scientific literature is limited for many of the indications tried. The most accepted uses of PNS involves one of 
two methods: 
 
    Open exposure of a peripheral nerve and direct implantation of a PNS electrode (as in treatment of a radial 
nerve, sciatic nerve, median nerve, etc.). 
    Percutaneous insertion of a PNS electrode in direct vicinity of the stimulated nerve (e.g., occipital nerve for 
severe headaches). 
 
As with a SCS and PNS, performance of an effective trial is a pre-requisite of final implantation. Many experts 
recommend that the temporary neurostimulator be placed in an Ambulatory Surgical Center (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 for the proper surgery and follow up of the 
patient are available. Permanent neurostimulators must be placed in an ASC or hospital. Physicians performing 
PNS trials in place of service office must have like privileges at an ASC or hospital, or the physician must be 
board certified or board eligible in Pain Medicine, Orthopedic Surgery, or Neurosurgery by an ABMS Board or 
the equivalent as determined by the state of practice. Other ABMS Specialty Boards or the equivalent in the 
state of practice may be included if such practice is included in the training program curriculum. 
 
It is preferable that the physicians performing the PNS trials will also perform the permanent implant. If the 
physician implanting the trial PNS does not or cannot implant the permanent neurostimulator(s), the patient 
should be informed of this in writing and given the name of the referral surgeon who will implant the 
permanent neurostimulator(s). 
 
Coverage of PNS trials requires that patients have all of the following: 
    Documented chronic and severe pain for at least 3 months, 
    Documented failure of less invasive treatment modalities and medications, 
    Lack of surgical contraindications including infections and medical risks, 
    Appropriate proper patient education, discussion and disclosure of risks and benefits, 
    No active substance abuse issues, 
    Formal psychological screening by a mental health professional, and 
    Successful stimulation trial with greater than or equal to 50% reduction in pain intensity before permanent 
implantation. 
 
The only reliable predictor of PNS effectiveness is a trial of stimulation with implanted PNS electrodes. If a 
trial fails, a repeat trial is usually not appropriate unless there are extenuating circumstances that led to the trial 
failure (equipment malfunction, early lead migration, etc.), technological advances, or an alternative 
neuromodulary technique that may lead to a more successful second trial. Documentation must explain these 
unusual situations. It is expected that accurate patient selection will lead to most patients going on to receive 
permanent implants. 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. 
 
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 imaging demonstrating proper 
lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for 
post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a 
favorable result of the trial implant; but careful selection should find the most appropriate patients. 
 
Examples of peripheral stimulation indications with evidence of efficacy that may be covered are: 
    PNS of occipital nerves for occipital neuralgia, post-surgical neuropathic pain, cervicogenic headaches and 
treatment resistant migraines. 
    PNS of trigeminal nerves (and branches) for post-traumatic and post-surgical neuropathic pain in the face 
related to the trigeminal nerves. 
    PNS of nerves in upper and lower extremities of complex regional pain syndromes (type 1 and 2), pain due 
to peripheral nerve injury, post-surgical scar formation, nerve entrapment, painful mononeuropathy, and 
painful amputation neuromas. 
    PNS of intercostal and ilio-inguinal nerves for post-surgical and post-traumatic neuropathic pain involving 
these nerve distributions. 
 
Current peer-reviewed data DOES NOT SUPPORT PNS for fibromyalgia, phantom limb pain, diffuse 
polyneuropathy, nociceptive pain in trunk or lower back, or angina pectoris. Claims for these indications will 
be denied as not reasonable and necessary. Current peer-reviewed data also is insufficient to warrant the 
medical necessity of coverage for PNFS for any condition. Therefore, this service will not be covered for any condition. You can find these rules in the Local Coverage Determination (LCD) Peripheral Nerve Stimulation 
L34328. 
 
The rules say that for 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 patients 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. 
 
For 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 these rules in the National 
Coverage Determination (NCD) 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.