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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.
Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for indications other than what is indicated on the official label may be covered if the use is determined to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.
The rules say that Chemodenervation techniques are indicated/covered for: 1. Chemodenervation of muscle innervated by the facial nerve in the management of blepharospasm or hemifacial spasm 2. Chemodenervation of cervical spinal muscles in the management of spasmodic torticollis 3. Chemodenervation of extremity muscles in the management of dystonias, cerebral palsy, upper and lower limb spasticity (see Note:) and multiple sclerosis 4. Chemodenervation of extraocular muscles in the management of strabismus 5. Chemodenervation of the lower esophageal sphincter in the management of achalasia 6. Chemodenervation of laryngeal muscles in the treatment of adductor spasmodic dysphonia 7. Chemodenervation of bilateral frontalis, trapezius, temporalis, sternocleidomastoid, and splenius capitis muscles for treatment of chronic tension headache and intractable daily headache 8. Chemodenervation of procerus and bilateral frontalis, corrugator, occipitalis, temporalis, trapezius, and cervical paraspinal muscle group for the prophylaxis of headaches in adult patients with chronic migraine (&#8805; 15 days per month with headache lasting 4 hours a day or longer) 9. Chemodenervation of sweat glands for the treatment of severe primary hyperhidrosis that is inadequately managed with topical agents. Severe is defined for this purpose as level 3 (sweating barely tolerable/frequently interferes with daily activity) or level 4 (sweating intolerable/always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS). 10. Chemodenervation of the internal anal sphincter for the treatment of chronic anal fissure 11. Chemodenervation of the detrusor urinae muscle for the treatment of over activity associated with a neurologic condition in adults with an inadequate response to anticholinergic treatment and for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication 12. Chemodenervation of the parotid and submandibular salivary glands, bilaterally
You can find this rule in the Local Coverage Determination for Chemodenervation, L33458 (eff 05/27/21).
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.