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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 a spinal orthosis (L0457) is covered when it is ordered for one of the following indications: 
 
    1. To reduce pain by restricting mobility of the trunk; or 
    2. To facilitate healing following an injury to the spine or related soft tissues; or 
    3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or 
    4. To otherwise support weak spinal muscles and/or a deformed spine. 
 
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically 
necessary. 
 
You can find this information in the Local Coverage Determination (LCD) for Spinal Orthoses: TLSO and 
LSO (L33790). 
 
 
  The rules say for any durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item to be 
covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's 
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 patient's diagnosis and other pertinent 
information including, but not limited to, duration of the patient's condition, clinical course (worsening or 
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, past experience with related items, etc. If an item requires a certificate of medical necessity (CMN) or 
DME information form (DIF), it is recommended that a copy of the completed CMN or DIF be kept in the 
patient's record. However, neither a physician's order, nor a CMN, nor a DIF, nor a supplier prepared 
statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even 
though it is signed by the treating physician or supplier. There must be information in the patient's medical 
record that supports the medical necessity for the item and substantiates the answers on the CMN (if 
applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if 
applicable). 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 5  Items and Services Having Special DME 
Review Considerations, Section 5.9  Documentation in the Patients Medical Record.  
 
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). 
 
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.