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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 based on information in the scientific literature, intra-operative testing may be considered reasonable and necessary for the following:

1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia
2. Resection of epileptogenic brain tissue or tumor
3. Resection of brain tissue close to the primary motor cortex and requiring brain mapping
4. Protection of cranial nerves

a. Resection of tumors involving the cranial nerves
b. Cavernous sinus tumors
c. Microvascular decompression of cranial nerves
d. Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum
e. Oval or round window graft

5. Endolymphatic shunt for Meniere's disease
6. Vestibular section for vertigo
7. Correction of scoliosis or deformity of spinal cord involving traction of the cord
8. Protection of spinal cord where work is performed in close proximity to cord as in the placement or removal of old hardware or where there have been numerous interventions
9. Spinal instrumentation requiring pedicle screws or distraction
10. Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk
11. Spinal cord tumors and spinal fractures (with the risk of cord compression)
12. Neuromas of peripheral nerves of brachial plexus, when there is risk to major sensory or motor nerves
13. Surgery or embolization for intracranial AV malformations
14. Surgery for arteriovenous malformation of spinal cord
15. Embolization of bronchial artery AVMs or tumors
16. Cerebral vascular aneurysms
17. Surgery for intractable movement disorders
18. Arteriography, during which there is a test occlusion of the carotid artery
19. Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass [e.g., CABG, ventricular aneurysms])
20. Distal aortic procedures, where there is risk of ischemia to spinal cord
21. Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks
22. Basal ganglia movement disorders
23. Surgery as a result of traumatic injury to spinal cord/brain
24. Deep brain stimulation, and
25. Certain thyroid surgeries

You can find this rule in the Local Coverage Determination (LCD) - Intraoperative Neurophysiological Testing (L35003).

The rules say that somatosensory evoked potentials and responses (SEPs/SERs) are appropriate for the following indications:

1. Spinal cord trauma
2. Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
3. Multiple sclerosis
4. Spinocerebellar degeneration
5. Myoclonus
6. Coma
7. Intraoperative monitoring
8. Subacute combined degeneration
9. Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease)
10. Syringomyelia
11. Hereditary spastic paraplegia

You can find this rule in the Local Coverage Determination (LCD) - Neurophysiology Evoked Potentials (NEPs) (L34975).

The rules say that nerve conduction studies and needle electromyography (NCS and NEMG) are considered medically reasonable and necessary when they are performed and interpreted at the same time, on site, and in real time for any of the following circumstances:

1. Plexopathy - including idiopathic, traumatic, inflammatory or infiltrative, radiation-induced, brachial plexopathies (e.g., neuralgic amyotrophy, thoracic outlet syndrome), and lumbosacral plexopathies (e.g., diabetic, non-diabetic lumbosacral radiculoplexus neuropathy)
2. Focal neuropathies (e.g., entrapment neuropathies or compressive lesions/syndromes such as carpal tunnel syndrome, ulnar neuropathy, tarsal tunnel syndrome, femoral neuropathy, saphenous neuropathy, lateral femoral cutaneous neuropathy, peroneal (fibular) neuropathy, tibial neuropathies, sciatic neuropathy)
3. Generalized neuropathies such as metabolic (e.g., diabetic, uremic), toxic, hereditary or immune-mediated
4. Motor neuron disease (e.g., amyotrophic lateral sclerosis [ALS] or Lou Gehrig's disease)
5. Myopathy - including inflammatory myopathies such as polymyositis and dermatomyositis, congenital myopathies, congenital and hereditary dystrophic and nondystrophic myopathies, including myotonic muscular dystrophy, acquired myopathies (drug induced myopathy associated with statins, thyroid related), metabolic myopathies (e.g., McArdle disease)
6. Myotonic disorders (e.g., drug induced myotonia)
7. Neuromuscular junction disorders (e.g., myasthenia gravis, Lambert-Eaton myasthenic syndrome, botulism)
8. Polyneuropathies
9. Radiculopathy - cervical, thoracic or lumbosacral
10. Spinal cord disorders (i.e., myelopathy)
11. Symptom-based presentations such as "pain in limb", weakness, cramping/twitching, disturbance of skin sensation or "paresthesia" when appropriate pre-test evaluations are inconclusive, and the clinical assessment unequivocally supports the need for the study
12. Traumatic nerve lesions, for diagnosis and prognosis

You can find this rule in the Local Coverage Determination (LCD) - Nerve Conduction Studies and Electromyography (L35081).

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