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). Coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). (See 160.13 of the NCD Manual for an explanation of coverage of medically necessary supplies for the effective use of NMES.) Use for Walking in Patients with Spinal Cord Injury (SCI) The type of NMES that is use to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy. Coverage for NMES/FES for walking will be covered in SCI patients with all of the following characteristics: - Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); - Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently; - Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical stimulation sufficient for muscle contraction; - Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; - Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes; - Persons that can demonstrate hand and finger function to manipulate controls; - Persons with at least 6-month post recovery spinal cord injury and restorative surgery; - Persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and - Persons who have demonstrated a willingness to use the device long-term. NMES/FES for walking will not be covered in SCI patient with any of the following: - Persons with cardiac pacemakers; - Severe scoliosis or severe osteoporosis; Skin disease or cancer at area of stimulation; - Irreversible contracture; or - Autonomic dysflexia. You can find this information in the National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12). 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.