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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 physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist, 
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program. 
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone 
for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is 
not considered medically reasonable and necessary. You can find this information in the Local Coverage 
Determination (LCD) Nerve Blocks for Peripheral Neuropathy L35249. 
 
The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure 
to an extremity for the purpose of reducing edema or lymphedema.  
Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury or 
lymphedema of an extremity. Education on the use of a lymphedema pump for home use is covered when 
medically necessary and can typically be completed in three (3) or fewer visits once the patient has 
demonstrated measurable benefit in the clinic environment. 
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the 
educational visits is generally not reasonable and necessary unless the patient presents with a condition or 
status requiring the skills and knowledge of a physical or occupational therapist. 
The use of vasopneumatic devices is generally not covered as a temporary treatment while awaiting receipt of 
ordered compression stockings.. 
 
Supportive Documentation Recommendations for vasopneumatic device therapy 
 
    Area of the body being treated, location of edema 
    Objective edema measurements (1+, 2+ pitting, girth, etc), comparison with uninvolved side 
    Effects of edema on function Type of device used 
 
You can find this information in the Local Coverage Determination (LCD) Outpatient Physical and 
Occupational Therapy Services L34049. 
 
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.