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). 
 
National Coverage Determination (NCD) Neuromuscular Electrical Stimulation (NMES) 160.12: 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: 
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve) 
2. 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 
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception electrical 
stimulation sufficient for muscle contraction 
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking 
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 
3 minutes 
6. Persons that can demonstrate hand and finger function to manipulate controls 
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery 
8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to 
osteoporosis; and 
9. Persons who have demonstrated a willingness to use the device long-term. 
National Coverage Determination (NCD) Pneumatic Compression Devices 280.6: Pneumatic compression 
devices are covered only when prescribed by a physician and when they are used with appropriate physician 
oversight, i.e., physician evaluation of the patient's condition to determine medical necessity of the device, 
assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used 
and the frequency and duration of use, and ongoing monitoring of use and response to treatment. 
The only time that a segmented, calibrated gradient pneumatic compression device (HCPCs code E0652) 
would be covered is when the individual has unique characteristics that prevent them from receiving 
satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented 
appliance or a segmented compression device without manual control of pressure in each chamber. 
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.