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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). 

It has come to Novitas' attention that auricular peripheral nerve stimulation has been billed to Medicare using the CPT code 64555. CPT code 64555 is described as: Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral nerve). The following devices are listed under the Food and Drug Administration (FDA) approval documents as electro-acupuncture devices used for stimulation of auricular acupuncture points and as such are non-covered. Acupuncture for stimulation of auricular points is not a covered Medicare benefit:

a. NeuroStim system/NSS
b. P-Stim 
c. ANSiStim 
d. E-Pulse 

The following device is FDA classified as a percutaneous nerve stimulator for substance use disorders; Class II device: 

NSS-2 Bridge

This device is an electrical nerve stimulator (percutaneous nerve field stimulator [PNFS] system) that is placed behind the patient's ear (auricular). The NSS-2 Bridge is described as nearly identical to the Electronic Auricular Device (EAD) for a different intended use (to aid in the reduction of opioid withdrawal symptoms). This device is non-covered by Medicare when used for acupuncture (stimulation of auricular acupuncture points) for any indication.

For additional information, please refer to National Coverage Determination (NCD) 30.3 for Acupuncture.

Coding Guidelines: The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system. Reporting: When billing for auricular peripheral nerve stimulation, use the NOC 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. 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.