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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 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 cervical traction devices (E0840, E0849, E0850, E0855 and E0860) are covered only if both 
of the following criteria are met: 
1. The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and 
2. The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the 
beneficiary tolerated the selected device. 
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary. 
 
Cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 and 2 above and 
either criterion A, B or C below has been met: 
A. The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received 
treatment for the TMJ condition; or, 
B. The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that 
a chin halter is unable to be utilized; or, C. The treating practitioner orders and/or documents the medical necessity for greater than 20 pounds of 
cervical traction in the home setting. 
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will 
be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD) 
Cervical Traction Devices L33823. 
 
The rules say that supplier-produced records, even if signed by the treating practitioner, and attestation letters 
(e.g., letters of medical necessity) are deemed not to be part of a medical record for Medicare payment 
purposes. Templates and forms, including Centers for Medicare & Medicaid Services (CMS) certificate of 
medical necessity (CMN), are subject to corroboration with information in the medical record. A prescription is 
not considered to be part of the medical record. Medical information intended to demonstrate compliance with 
coverage criteria may be included on the prescription but must be corroborated by information contained in the 
medical record. The beneficiarys medical record must contain sufficient documentation of the beneficiarys 
medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency 
of use or replacement (if applicable). The information should include the beneficiarys diagnosis and other 
pertinent information including, but not limited to, duration of the beneficiarys condition, clinical course 
(worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic 
interventions and results, past experience with related items, etc. You can find this rule in Local Coverage 
Article Standard Documentation Requirements for All Claims Submitted to DME MACs A55426. 
 
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.