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 A. 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 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. 

B. 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 this information in Medicare's National Coverage Determination (NCD): Electrical Nerve Stimulators (160.7).

The rules say Covered Indications: 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. 

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. 

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD. You can find this information in Medicare's 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.