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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 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: 
 
1. The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic 
intractable pain; 
2. With respect to item 1, 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; 
3. 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); 
4/ 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 
5. Demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 
 
You can find this rule in National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) - 
Effective August 7, 1995. 
 
The rules say that the implantation of spinal cord stimulators may be covered as therapies for the relief of 
chronic intractable pain. It is best suited for neuropathic pain, but may have some limited value in other types 
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. You can find this rule in the Local Coverage Determination (LCD) - Spinal 
Cord Stimulators for Chronic Pain (L36204) - Effective December 1, 2019. 
 
The rules say that selection of patients for implantation of spinal cord stimulators is critical to the success of 
this therapy. This 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 
 
You can find this rule in the Local Coverage Determination (LCD) - Spinal Cord Stimulators for Chronic Pain 
(L36204) - Effective December 1, 2019. 
 
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.