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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 rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
The rules say that a patient must have at least 1 of the following: 
 
1. Radiographic or clinical evidence of instability due to any 1 of the following: 
 
     a. Congenital deformities, 
     b. Trauma, 
     c. Fractures, 
     d. Chronic degenerative conditions, 
     e. Tumor,      f. Infection, 
     g. Erosive conditions, 
     h. Space-occupying lesions, or 
     i. Iatrogenic causes, including expected instability as a consequence of another medically necessary spine 
procedure. 
 
      If more than 1 level is fused under this indication, the record must reflect that each fused level is affected 
by 1 of the above conditions. 
 
 2. Symptomatic spinal deformity (in the absence of instability or neural compression) which meets the 
following criteria: 
 
     Both of the first 2 criteria must be met: 
 
     a. Functional limitation in daily activities due to back pain or discomfort and 
 
     b. Nonresponse to at least 1 year of non-operative treatment 
 
     Any 1 of these 3 criteria must be met: 
 
     c. Sagittal or coronal imbalance by at least 5 cm as measured on radiographic imaging of the entire spine, or 
     d. Progression of deformity by at least 10 degrees, or 
     e. Scoliotic curvature of greater than 30 degrees 
 
 3. Revision surgery for pseudarthrosis following an initial spine surgery if the following conditions are all met. 
 
     a. The patient had a period of reduced pain initially following surgery and 
 
     b. The time since the prior surgery has been at least 1 year and 
 
     c. There is clear radiographic evidence of pseudarthrosis  and 
 
     d. The patient has exhausted available conservative treatment measures 
 
The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate 
for and why, including medical therapies, physical and exercise therapies and injections. Outcomes for fusion 
in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment 
option only when all other treatment options have failed. This information must be communicated to the patient 
prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical 
record must reflect that this counseling was done and that the patient wished to undergo surgery with the 
appropriately informed consent. 
 
 4. Symptomatic compression of neural elements for which disc excision is necessary for decompression. The 
record must reflect disc compression of neural elements for each level fused based on this indication. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Lumbar Spinal Fusion 
(L37848). 
 
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.