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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 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).
Electro-acupuncture devices, including but not limited to P-STIM devices, are applied behind the ear using
an adhesive and/or with needles inserted into the patient's ear (similar to acupuncture). Providers are
inappropriately coding electro-acupuncture devices as implantable neurostimulators (HCPCS L8679 -
implantable neurostimulator, pulse generator, any type), which are Medicare-covered devices that require
surgical implantation into the central nervous system or targeted peripheral nerve, and are usually implanted
via procedures performed in operating rooms (see CMS Publication 100-03, National Coverage Determination
(NCD) Manual, Section 160.7). While both devices can be used to treat chronic pain, the electro-acupuncture
devices are non-invasive (that is, do not require surgical implantation and/or an incision), and have an external
battery source. Electro-acupuncture devices and implantable neurostimulators are two separate devices, and
coding electro-acupuncture devices as implantable neurostimulators is incorrect. Also, HCPCS L8679, when
appropriately billed for an implantable neurostimulator pulse generator, should be submitted with the
appropriate HCPCS/CPT surgical procedural code.
You can find this information in Medicare Learning Network (MLN) Matters SE20001, Incorrect Billing of
HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type.
Due to multiple claims received related to inappropriate billing of PERCUTANEOUS ELECTRICAL NERVE
STIMULATION (PENS) and percutaneous neuromodulation therapy (PNT), this article is being published to
provide clarification. Providers are required to bill procedure codes that exactly describe the service performed
and currently there are no specific Current Procedural Terminology (CPT) codes for PENS or PNT.
Therefore, unlisted CPT code 64999 (Unlisted procedure, nervous system) should be used to report
PERCUTANEOUS ELECTRICAL NERVE STIMULATION and percutaneous neuromodulation therapy.
CPT codes for percutaneous implantation of neurostimulator electrodes (i.e., CPT 64553 - 64565) are also
not appropriate given PENS and PNT use percutaneously inserted needles and wires rather than percutaneously
implanted electrodes.
Additionally, the stimulation devices used in PENS and PNT are not implanted, therefore CPT code 64590 is
also not appropriate.
You can find this information in Local Coverage Article - Percutaneous electrical nerve stimulation (PENS)
and percutaneous neuromodulation therapy (PNT) (A54794).
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.