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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 Original Medicare pays physicians, providers and suppliers for Medicare-covered services
furnished to enrollees who have elected hospice. The Plan is responsible for non-hospice services that are not
Medicare-covered, but that are offered as supplemental benefits under the Plan. You can find this rule in the
Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Managed Care Manual, Chapter
8, Section 70.3.1.
The rules also say that the Medicare hospice pays claims for services related to the terminal illness. Original
Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or
suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the
enrollee's hospice election until the first day of the month after the hospice election has been revoked or
terminated. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual,
Medicare Claims Processing Manual, Chapter 11, Section 30.4.
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 postsurgical
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 (e.g., dyskinesias, motor fluctuations, or
disabling "off" periods) despite optimal medical therapy.
e. Willingness and ability to cooperate during conscious operative procedure, as well as during postsurgical
evaluations, adjustments of medications and stimulator settings.
You can find more information at the National Coverage Determination (NCD) for Deep Brain Stimulation for
Essential Tremor and Parkinson's Disease (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.