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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). 
 
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. 
 
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. 
 
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.