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The rules say that plans must pay for a medical service or item ifregular 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:Transthoracic EchocardiogramINDICATIONS:1. Ventricular Function, Cardiomyopathies and Heart Failure2. Hypertensive Cardiovascular Disease3. Acute Myocardial Infarction and Coronary Insufficiency4. Exposure to Cardiotoxic Agents (chemotherapeutic and external) 5. Cardiac Transplant and Rejection Monitoring6. Native Valvular Heart Disease7. Prosthetic Heart Valves (Mechanical & Bio-prostheses)8. Acute Endocarditis9. Pericardial Disease10. Abnormalities of the GreatVessels11. Congenital Heart Disease12. Suspected Cardiac Thrombi and Embolic Sources13. Cardiac Tumors and Masses14. Critically Ill and Trauma Patients15. Arrhythmias and Palpitations16. Syncope17. PulmonaryLIMITATIONS:1. Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor as having a positive family history, e.g., familial history of Marfan's disease). A screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition.The following indications (#2-15) are deemed to be not medically necessary and are therefore not reimbursable:2. Routine (yearly) evaluation of asymptomatic patients with corrected ASD, VSD or PDA more than one year after successful correction.3. Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no change in clinical status.4. Routine (yearly) re-evaluation of an asymptomatic patient with mild native aortic stenosis or mild-moderate native mitral stenosis and no change in clinical status.5. Routine (yearly) re-evaluation of native valvular regurgitation in an asymptomatic patient with mild regurgitation, no change in clinical status and normal left ventricular size.
6. Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status.7. Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status.8. Routine (yearly) evaluation of hypertrophic cardiomyopathy in a patient with no change in clinical status.9. Patients who have isolated APC or VPC without other evidence of heart disease. 10. Evaluation of LV function with prior ventricular function within the past year with normal (such as prior echocardiogram, left ventriculogram, SPECT, cardiac MRI) in patients in whom there has been no change in clinical status.11. Initial evaluation of patient with suspected pulmonary embolism in order to establish diagnosis.12. Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of bacteremia or new murmur.13. Re-evaluation of a patient with known hypertensive heart disease without a change in clinical status.14. Routine evaluation of patients with systemic hypertension without suspected hypertensive heart disease.15. Evaluation of a patient with atrial fibrillation/flutter for left atrial thrombus or spontaneous contrast when a decision has been made to anticoagulate and not to perform cardioversion.You can find this rule in the Local Coverage Determination (LCD): Transthoracic Echocardiography (TTE) (L33577) effective October 1, 2019.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.