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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 effective for services furnished on or after April 1, 2003, Medicare will cover unilateral or 
bilateral thalamic ventralis intermedius nucleus (VIM) deep brain stimulation (DBS) for the treatment of 
essential tremor (ET) and/or Parkinsonian tremor and unilateral or bilateral subthalamic nucleus (STN) or 
globus pallidus interna (GPi) DBS for the treatment of Parkinson's disease (PD) only under the following 
conditions: 
1. Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug 
Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols 
governing Category B Investigational Device Exemption (IDE) DBS clinical trials. 
2. For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following 
criteria: 
a. diagnosis of ET based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis 
of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a 
tremor-dominant form. 
b. Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or 
equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities 
despite optimal medical therapy. 
c. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical 
evaluations, adjustments of medications and stimulator settings. 
 
3. For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following 
criteria: 
a. Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia). 
b. Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease 
Rating Scale (UPDRS) part III motor subscale. 
c. L-dopa responsive with clearly defined "on" periods. 
d. Persistent disabling Parkinson's symptoms or drug side effects despite optimal medical therapy. 
e. Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical 
evaluations, adjustments of medications and stimulator settings. 
 The DBS is not reasonable and necessary and is not covered for ET or PD patients with any of the following: 
1. Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes. 
2. Cognitive impairment, dementia or depression, which would be worsened by or would interfere with the 
patient's ability to benefit from DBS. 
3. Current psychosis, alcohol abuse or other drug abuse. 
4. Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the 
movement disorder. 
5. Previous movement disorder surgery within the affected basal ganglion. 
6. Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS surgery or 
stimulation. 
 
Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including 
shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI, which may 
adversely affect the DBS system or adversely affect the brain around the implanted electrodes. The DBS should 
be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled 
implants, which may adversely affect or be affected by the DBS system. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 160.24. 
 
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.