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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 CFR 422.101.
The rules say that echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function. The general applications for coverage include: 1. Ventricular Function, Cardiomyopathies and HeartFailureChanges in myocardial thickness (hypertrophy and thinning), in derived parameters of contractility, and in chamber volume and morphology, can be quantitated and charted over time by TTE. Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional perturbations to a clinical presentation is facilitated. TTE aids in the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more frequent than annual examinations.There is increasing data to support the prognostic value of diastolic function parameters in patients with systolic dysfunction. "When the etiology is in doubt, echocardiography can document or rule out the common cardiac causes of pulmonary congestion: left-sided valvular disease, depressed systolic or diastolic function, and cardiomyopathy. In this regard, echocardiography is the preferred initial diagnostic test when the history, physical examination, and routine laboratory tests suggest (or cannot eliminate) cardiac disease." (ACC/AHA/ASE 2003 Guideline Update, pg. 35) "Echocardiography is recommended for patients with edema with clinical signs of elevated central venous pressure when a potential cardiac etiology issuspected or when central venous pressure cannot be estimated with confidence and clinical suspicion of heart disease is high." TTE is also recommended for patients experiencing "dyspnea with clinical signs of heart disease."(ACC/AHA/ASE 2003 Guideline Update, pg. 37) "Echocardiography is not recommended in patients with edema when the jugular venous pressure does not appear to be elevated." (ACC/AHA/ASE 2003 Guideline Update, pg. 35).2. Hypertensive Cardiovascular Disease"Echocardiography is the noninvasive procedure of choice in evaluating the cardiac effects of systemic hypertension, the most common cause of LV hypertrophy and congestive heart failure in adults." (ACC/AHA/ASE 2003 Guideline Update, pg. 42) Left ventricular hypertrophy (LVH) correlateswith prognosis in hypertensive cardiovascular disease. However, "the usefulness of echocardiography in an individual patient with hypertension without suspected concomitant heart disease depends on the clinical relevance of the assessment of LV mass or function in that patient. Thus, not every patient with hypertension should have resting LV function assessed (Class I), but if such an assessment is relevant, echocardiography is a well-documented and accepted method by which to achieve it. The value of repeated studies in asymptomatic hypertensive patients with normal LV function is not clearly established." (ACC/ AHA 2003 Guideline Update, pg. 42).Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapymay be determined by the presence of left ventricular hypertrophy and /or left ventricular mass calculation.You can find this rule in Local Coverage Determination (LCD): Transthoracic Echocardiography (TTE) (L34338) -Effective September 26, 2019.Ifyou want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.