(Medicare National Coverage Determinations Manual)

160.8 - Electroencephalographic Monitoring During Surgical Procedures Involving the Cerebral Vasculature  (Rev. 48, Issued:  03 -17-06; Effective/Implementation Dates:  06 -19-06) CIM 35 -57  Electroencephalographic (EEG) monitoring is a safe and reliable technique for the assessment of gross cerebral blood flow during general anesthesia and is covered under Medicare.  Very characteristic changes in the EEG occur when cerebral perfusion is inadequate for cere bral function.  EEG monitoring as an indirect measure of cerebral perfusion requires the expertise of an electroencephalographer, a neurologist trained in EEG, or an advanced EEG technician for its proper interpretation.   The EEG monitoring may be covered routinely in carotid endarterectomies and in other neurological procedures where cerebral perfusion could be reduced.  Such other procedures might include aneurysm surgery where hypotensive anesthesia is used or other cerebral vascular procedures where cerebral blood flow may be interrupted.  160.9  Electroencephalographic (EEG) Monitoring During Open -Heart Surgery  (RETIRED)  (Rev. 11892; Issued: 03- 09-23; Effective: 04 -10-23; Implementation:04- 10-23)    Effective December  18, 2014, NCD 160.9 is  retired.   160.10 - Evoked Response Tests  (Rev. 1, 10-03-03) CIM 50 -31  Evoked response tests, including brain stem evoked response and visual evoked response tests, are generally accepted as safe and effective diagnostic tools.  These tests measure brain responses to repetitive visual, click or other stimuli.  Program payment may be made for these procedures.  160.12 - Neuromuscular Electrical Stimulator (NMES)  (Rev. 55, Issued: 05-05- 06, Effective: 10 -01-06, Implementation: 10-02-06)  Neuromuscular electrical stimulation (NMES) involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. There are two broad categories of NMES. One type of device stimulates the muscle wh en the patient is in a resting state to treat muscle atrophy. The second type is used to enhance functional activity of neurologically impaired patients.  Treatment of Muscle Atrophy  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 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 use 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 persons 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 unite (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 with 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.   The 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.   The only settings where therapists with the sufficient skills to provide these services are employed, are inpatient hospitals; outpatient hospitals; comprehensive outpatient rehabilitation facilities; and outpatient rehabilitation facilities.  The physical therapy necessary to perform this training must be part of a one -on-one training program.  Additional therapy after the purchase of the DME would be limited by our general policies in converge of skilled physical therapy.   (Also reference the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 220 and 230, and the Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF Services, 10.1.)   160.13 - Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES)  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Transcutaneous Electrical Nerve Stimulation (TENS) and/or Neuromuscular Electrical Stimulation (NMES) can ordinarily be delivered to patients through the use of conventional electrodes, adhesive tapes and lead wires.  There may be times, however, where it might be medically necessary for certain patients receiving TENS or NMES treatment to use, as an alternative to conventional electrodes, adhesive tapes and lead wires, a form -fitting conductive garment (i.e., a garment  with conductive fibers which are separated from the patients skin by layers of fabric).   A form -fitting conductive garment (and medically necessary related supplies) may be covered under the program only when:   1. It has received permission or approval for marketing by the Food and Drug Administration;   2. It has been prescribed by a physician for use in delivering covered TENS or NMES treatment; and   3. One of the medical indications outlined below is met:    The patient cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes and lead wires;    The patient cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes and lead wires;    The patient has a documented medical condition such as skin problems that preclude the application of conventional electrodes, adhesive tapes and lead wires;    The patient requires electrical stimulation beneath a cast either to treat disuse atrophy, where the nerve supply to the muscle is intact, or to treat chronic intractable pain; or    The patient has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact.   A conductive garment is not covered for use with a TENS device during the trial period specified in 160.3 unless:   4. The patient has a documented skin problem prior to the start of the trial period; and   5. The A/B MAC (B)'s medical consultants are satisfied that use of such an item is medically necessary for the patient.   (See conditions for coverage of the use of TENS in the diagnosis and treatment of chronic intractable pain in 160.3, 160.13, and 160.27, and the use of NMES in the treatment of disuse atrophy in 150.4.)   160.14 - Invasive Intracranial Pressure Monitoring  (Rev. 1, 10- 03-03) CIM 35 -62  Invasive intracranial pressure monitoring is a safe and effective therapeutic tool used to monitor intracranial pressure.  It is usually used for patients suffering from head injuries, subarachnoid hemorrhage, intracerebral hemorrhage, Reyes syndrome, or posthypoxic, metabolic, and viral encephalopathies.  It is usually performed in specialized intensive care units for neurosurgical and neurologic patients.  It is a covered procedure when reasonable and necessary for the individual patient.  160.15 - Electrotherapy for Treatment of Facial Nerve Palsy (Bells Palsy)  (Rev. 1, 10- 03-03) CIM 35 -72  Not Covered   Electrotherapy for the treatment of facial nerve paralysis is the application of electrical stimulation to affected facial muscles to provide muscle innervation with the intention of preventing muscle degeneration.  A device that generates an electrical cu rrent with controlled frequency, intensity, wave form and type (galvanic or faradic) is used in combination with a pad electrode and a hand applicator electrode to provide electrical stimulation.   Electrotherapy for the treatment of facial nerve paralysis, commonly known as Bells Palsy, is not covered under Medicare because its clinical effectiveness has not been established.   160.16 - Vertebral Axial Decompression (VAX -D) (Rev. 1, 10-03-03) CIM 35 -97  Not Covered  Vertebral axial decompression is performed for symptomatic relief of pain associated with lumbar disk problems.  The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application.  There is insufficie nt scientific data to support the benefits of this technique.  Therefore, VAX-D is not covered by Medicare.   160.17 - L-Dopa (Rev. 1, 10-03-03) CIM 45 -1  A.  Part A Payment for L-Dopa and Associated Inpatient Hospital Service  A hospital stay and related ancillary services for the administration of L- Dopa are covered if medically required for this purpose.  Whether a drug represents an allowable inpatient hospital cost during such stay depends on whether it meets the definition of a drug in 1861(t) of the Act; i.e., on its inclusion in the compendia named in the Act or approval by the hospitals pharmacy and drug therapeutics (P&DT) or equivalent committee.  (Levodopa (L-Dopa) has been favorably evaluated for the treatment of Parkinsonism by A.M.A. Drug Evaluations, First Edition 1971, the replacement compendia for New Drugs.")  Inpatient hospital services are frequently not required in many cases when L-Dopa therapy is initiated.  Therefore, determine the medical need for inpatient hospital services on the basis of medical facts in the individual case.  It is not necessary to hospitalize the typical, well-functioning, ambulatory Parkinsonian patient who has no concurrent disease at the start of L -Dopa treatment.  It is  reasonable to provide inpatient hospital services for Parkinsonian patients with concurrent diseases, particularly of the cardiovascular, gastrointestinal, and neuropsychiatric systems.  Although many patients require hospitalization for a period of under two weeks, a 4-week period of inpatient care is not unreasonable.  Laboratory tests in connection with the administration of L-Dopa - The tests medically warranted in connection with the achievement of optimal dosage and the control of the side effects of L -Dopa include a complete blood count, liver function tests such as SGOT, SGPT, and/or alkaline phosphatase, BUN or creatinine and urinalysis, blood sugar, and electrocardiogram.