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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 Code of Federal Regulations (CFR) Section 422.101.

The rules say that the following are covered indications for Duplex scans, Doppler Ultrasound with Spectrum Analysis, Ocular Pneumoplethysmography, and Periorbital Doppler:

o Evaluation of patients with a cervical bruit
o Evaluation of pulsatile neck masses
o Evaluation of patients with hemispheric neurologic symptoms, including stroke, transient ischemic attack and amaurosis fugax
o Follow-up of patients with proven carotid disease who are receiving medical therapy
o Follow-up for postoperative patients following carotid endarterectomy, stenting or carotid to subclavian bypass
o Evaluation of suspected subclavian steal syndrome
o Evaluation of retinal arterial emboli
o Evaluation of suspected carotid artery dissection or pseudoaneurysm
o Evaluation of sudden and lateralizing neurologic deficit
o Established or symptomatic coronary artery disease or cardiac valvular disease
o "Drop attacks" or syncope when there are documented signs or symptoms consistent with vertebral basilar or carotid artery disease or insufficiency

Limitations

1. Non-invasive vascular studies done for screening purposes (i.e., without signs or symptoms of disease) are considered not reasonable and necessary and are therefore non-covered by Medicare. Examples of screening studies include but are not limited to:

o Extracranial arterial studies performed as part of a cardiovascular preoperative workup in the absence of signs or symptoms of disease are screening services and as such are non-covered by Medicare.
o Subclavian ultrasound studies routinely performed in conjunction with carotid ultrasounds in the absence of signs or symptoms of disease are screening services and as such are non-covered by Medicare.

2. Non-invasive vascular studies are considered not reasonable and necessary if the results are not needed for clinical decision making. If the study results will have no impact on the decision for further diagnostic or therapeutic procedures or will not provide any unique diagnostic information that would impact patient management, then the non-invasive studies are not reasonable and necessary. For example, if it is evident from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not reasonable and necessary.

You can find this rule in the Local Coveraqe Determination (LCD): Non-Invasive Cerebrovascular Arterial Studies (L35397).

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.