(Medicare National Coverage Determinations Manual)

Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye exa mination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A -scan or, if medically justified, a B -scan.  Claims for additional tests are denied as not reasonable and necessary unless there  is an additional diagnosis and the medical need for the additional tests is fully documented.  Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician.  In these situations, it may be medically appropriate for the operating physician to conduct another examination.  To the extent the additional tests are considered reasonable and necessary by the A/B MAC's medical staff , they are covered.   B.  General Anesthesia   The use of general anesthesia in cataract surgery may be considered reasonable and necessary if, for particular medical indications, it is the accepted procedure among ophthalmologists in the local community to use general anesthesia.   10.2 - Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  The use of transcutaneo us electrical nerve stimulation (TENS) for the relief of acute post-operative pain is covered under Medicare.  TENS may be covered whether used as an adjunct to the use of drugs, or as an alternative to drugs, in the treatment of acute pain resulting from surgery.   The TENS devices, whether durable or disposable, may be used in furnishing this service. When used for the purpose of treating acute post -operative pain, TENS devices are considered supplies.  As such they may be hospital supplies furnished inpat ients covered under Part A, or supplies incident to a physicians service when furnished in connection with surgery done on an outpatient basis, and covered under Part B.   It is expected that TENS, when used for acute post -operative pain, will be necessary  for relatively short periods of time, usually 30 days or less.  In cases when TENS is used for longer periods, A/B MACs should attempt to ascertain whether TENS is no longer being used for acute pain but rather for chronic pain, in which case the TENS device may be covered as durable medical equipment as described in 160.27.  Cross -references:  Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 40;  Medicar e Benefit Policy Manual, Chapter 2, Hospital Services Covered Under Part B, 20, 20.4, and 80; Medicare Benefit Policy Manual, Chapter 15, Covered Medical and other Health Services, 110.   10.3 - Inpatient Hospital Pain Rehabilitation Programs  (Rev. 1, 10- 03-03) CIM 35 -21  Pain rehabilitation programs are an innovative approach to the treatment of intractable pain.  The goal of such programs is to give a patient the tools to manage and control his/her pain and thereby improve his/her ability to function independently.   A hospital level pain rehabilitation program is one that employs a coordinated multi -disciplinary team to deliver, in a controlled environment, a concentrated program that is desig ned to modify pain behavior through the treatment of the physiological, psychological, and social aspects of pain.  Such programs generally include diagnostic testing, skilled nursing, psychotherapy, structured progressive withdrawal from pain medications,  physical therapy, and occupational therapy to restore physical fitness (mobility and endurance) to a maximal level within the constraints of a patients physical disability, and the use of mechanical devices, and/or activities to relieve pain or modify a patients reaction to it (e.g., nerve stimulator, hydrotherapy, massage, ice, systemic muscle relaxation training, and diversional activities).   The nurses responsibility in such pain rehabilitation programs is to observe and assess, on a continuing basis , a patients condition and response to the program as reflected by his actions while in the nursing unit, and to assure that the atmosphere within the unit is not supportive of pain behavior. The day -to-day activities involved in carrying out the program are under the general supervision and, as needed, direct supervision of a physician.  Since pain rehabilitation programs of a lesser scope than that described above would raise a question as to whether the program could be provided in a less intensive sett ing than on an inpatient hospital basis, carefully evaluate such programs to determine whether the program does, in fact, necessitate a hospital level of care.  Some pain rehabilitation programs may utilize services and devices which are excluded from cove rage, e.g., acupuncture dorsal column stimulator, and family counseling services.  In determining whether the scope of a pain program does necessitate inpatient hospital care, evaluate only those services and devices which are covered.  Although diagnostic  tests may be an appropriate part of pain rehabilitation programs, such tests would be covered in an individual case only where they can be reasonably related to a patients illness, complaint, symptom, or injury and where they do not represent an unnecess ary duplication of tests previously performed.   An inpatient program of 4 weeks duration is generally required to modify pain behavior. After this period, it would be expected that any additional rehabilitation services which might be required could be ef fectively provided on an outpatient basis under an outpatient pain rehabilitation program (see 10.4 ) or other outpatient program.  The first 7-10 days of such an inpatient program cons titute, in effect, an evaluation period.  If a patient is unable to adjust to the program within this period, it is generally concluded that it is unlikely that the program will be effective and the patient is discharged from the program.  On occasions, a program longer than four weeks may be required in a particular case.  In such a case, there should be documentation to substantiate that inpatient care beyond a 4 -week period was reasonable and necessary.  Similarly, where it appears that a patient partici pating in a program is being granted frequent outside passes, a question would exist as to whether an inpatient program is reasonable and necessary for the treatment of the patients condition.   An inpatient hospital stay for the purpose of participating i n a pain rehabilitation program would be covered as reasonable and necessary to the treatment of a patients condition where the pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability to function independently has resulted from the pain. Chronic pain patients often have psychological problems which accompany or stem from the physical pain, and it is appropriate to include psychological treatment in the multi- disciplinary approach. However, patients whose pain symptoms result from a mental condition, rather than from any physical cause, generally cannot be successfully treated in a pain rehabilitation program.   10.4 - Outpatient Hospital Pain Rehabilitation Program s (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Some hospitals also provide pain rehabilitation programs for outpatients.  In such programs, services frequently are provided in group settings even though they are being furnished pursuant to each patients individualized plan of treatment.   Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patients pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by the patient to function independently has resulted from the pain.  If a patient meets these conditions and the program provides services of the types discussed in 10.3, the services provided under the program may be covered.  Non -covered services (e.g., vocational counseling, meals for outpatients, or acupuncture) continue to be excluded from coverage, and A/B MACs would not be precluded from finding, in the case of particular patients, that the pain rehabilitation program is  not reasonable and necessary under 1862(a)(1)  of the Social Security Act for the treatment of their conditions.  10.5 - Autogenous Epidural Blood Graft  (Rev. 1, 10- 03-03) CIM 45 -11  Autogenous epidural blood grafts are considered a safe and effective remedy for severe headaches that may occur after performance of spinal anesthesia, spinal taps or myelograms, and are covered.  In the procedure, blood is removed from the patients vein and injected into his epidural space, to seal the spinal fluid leak and stop the pain.   10.6 - Anesthesia in Cardiac Pacemaker Surgery  (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  The use of general or monitored anesthesia during transvenous cardiac pacemaker surgery may be reasonable and necessary and therefore covered under Medicare only if adequate documentation of medical necessity is provided on a case -by-case basis.  The A/B MAC obtains advice from its medical consultants or from appropriate specialty physicians or groups in its locality regarding the adequacy of documentation before deciding whether a particular claim should be covered.   A second type of pacemaker surgery that is sometimes performed involves the use of the thoracic method of implantation which requires open surgery.  Where the thoracic method is employed, general anesthesia is always used and should not require special medical documentation.   20 - Cardiovascular  System  (Rev. 1, 10- 03-03)  20.1 - Vertebral Artery Surgery  (Rev. 1, 10- 03-03) CIM 35 -32  Obstructions which block the flow of blood through the vertebral artery can cause vertigo, visual or speech defects, ataxia, mental confusion, or stroke.  These symptoms in patients result from reduction in blood flow to the brain and range from symptoms of transient basilar ischemia to mental deterioration or completed stroke.   Five types of surgical procedures are performed to relieve obstructions to vertebral a rtery blood flow.  They are:    Vertebral artery endarterectomy, a procedure which cleans out arteriosclerotic plaques which are inside the vertebral artery;    Vertebral artery by -pass or resection with anastomosis or graft;    Subclavian artery resection with or without endarterectomy;    Removal of laterally located osteophytes anywhere in the C6 (C7) -C2 course of the vertebral artery; and    Arteriolysis which frees the artery from surrounding tissue, with or without arteriopexy ( fixation of the vessel).   These procedures can be medically reasonable and necessary, but only if each of the following conditions is met:    Symptoms of vertebral artery obstruction exist;    Other causes have been considered and ruled out;    There is radiogra phic evidence of a valid vertebral artery obstruction; and    Contraindications to the procedure do not exist, such as coexistent obstructions of multiple cerebral vessels.   Angiograms documenting a valid obstruction should show not only the aortic arch wit h the vessels off the arch, but also show the vessels in the neck and head (providing biplane views of the carotid and vertebral vascular system).  In addition, serial views are needed to diagnose subclavian steal, the condition in which subclavian arter y obstruction causes the symptoms of vertebral artery obstruction.  Because the symptoms are not specific for vertebral artery obstruction, other causes must be considered.  In addition to vertebral artery obstruction, the differential diagnosis should inc lude various degenerative disorders of the brain, orthostatic hypotension, acoustic neuroma, labyrinthitis, diabetes mellitus and hypoglycemia related disorders.   Obstructions which can cause symptoms of blocked vertebral artery blood flow and which can be documented by an angiogram include:    Intravascular obstructions -  arteriosclerotic lesions within the vertebral artery or in other arteries.    Extravascular obstructions;   Bony tissue or osteophytes, located laterally in the C6 (C7) -C2 cervical vertebral area course of the vertebral artery, most commonly at C5 - C6;   Anatomical variations -  Anomalous location of the origin of the vertebral artery, a congenital aberra tion, and tortuosity and kinks of the vertebral artery; to