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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 state that the medical effectiveness of the above therapies (prolotherapy) has not been verified by 
scientifically controlled studies. Accordingly, reimbursement for these modalities should be denied on the 
ground that they are not reasonable and necessary as required by 1862(a)(1) of the Act. You can find this rule 
at the Medicare National Coverage Determination (NCD) 150.7: Prolotherapy, Joint Sclerotherapy, and 
Ligamentous Injections with Sclerosing Agents. 
 
The rules state that 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 used 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: 
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. 
NMES/FES for walking will not be covered in SCI patient with any of the following: 
1. Persons with cardiac pacemakers; 
2. Severe scoliosis or severe osteoporosis; 
3. Skin disease or cancer at area of stimulation; 
4. Irreversible contracture; or 
5. Autonomic dysflexia. 
You can find this rule at the Medicare National Coverage Determination (NCD) 160.12: Neuromuscular 
Electrical Stimulation (NMES). 
 
The rules state that pneumatic devices are covered for the treatment of lymphedema or for the treatment of 
chronic venous insufficiency with venous stasis ulcers. You can find this rule at the Medicare National 
Coverage Determination (NCD) 280.6: Pneumatic Compression Devices. 
 
The rule state that an active trigger point has pain at rest, has pain on palpitation, has radiation of pain, and has 
a local twitch response. Trigger point injections are indicated in symptomatic trigger points. The history of 
onset of the painful condition and its presumed cause, location, duration, failed therapies and recommendations 
for injection therapy of each clearly delineated muscle must be in the patients chart and made available to 
Medicare upon request. The goal is to treat the cause of the pain and not just the symptom of pain. 
 
Limitations 
 
1. Trigger point injections accompanied by appropriate adjunctive care should provide moderate-
to-long term benefits. There is no peer-reviewed literature to substantiate more than four trigger 
point injections in a year. 
2. Prolotherapy is not covered by Medicare. If prolotherapy is billed using trigger point therapy 
codes, it will be considered not reasonable and necessary. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L37635: Trigger Point Injections. 
 
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.