Appeal type: unknown
Decision: unknown

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. The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the Current Procedural Terminology (CPT) code 64999 - unlisted procedure, nervous system. When billing for Auricular Peripheral Nerve Stimulation, use the CPT code 64999 - unlisted procedure, nervous system. The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B. The service for Auricular Peripheral Nerve Stimulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the
Act. While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim, E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure Auricular Peripheral Nerve Stimulation or electro-acupuncture, would also be considered a non-covered service. You can find this information in Local Coverage Article: Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) A55240.
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