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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 that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say 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. 
 
Selection of patients for implantation of SCS 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. 
 
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-to-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%) may/can/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. 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. 
 
Local Coverage Determination (LCD): Spinal Cord Stimulators for Chronic Pain (L37632). 
 
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.