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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). The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows: - The paravertebral facet joint(s) have been identified as the source of the patient's pain by undergoing a diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and - The patient failed conservative treatment. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic and - The paravertebral facet joint(s) destruction is performed by appropriately trained providers. If pain recurs in the same distribution and nature, the procedure may be provided at the same anatomic site (side and spinal level) 6 months from prior treatment. The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary when: - Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint (median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or - The medical records do not support that the patient experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection; or - The medical records do not demonstrate that destruction was performed at the median branch of the spinal nerve innervating the facet joint. - It is not expected that paravertebral facet joint destructions (median branch) will exceed five (5) levels, unilaterally or bilaterally on the same date of service. - Repeat paravertebral facet joint destruction is not medically necessary when performed at the same anatomic site (side and spinal level) within 6 months of a prior treatment. (So one bilateral or R(L) then L(R) same level is allowed in 6 months and then can be repeated in the subsequent 6 months. You can find this information in the Local Coverage Determination (LCD): Destruction of Paravertebral Facet Joint Nerve(s) (L33814). The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3 3.3.2.1.
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.