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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 Radionuclide imaging may be employed in the assessment of a variety of conditions associated with primary coronary artery disease. Some of these conditions include: 1. Assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent symptoms. 2. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG/EKG changes occurring naturally or caused by drugs, bundle branch block, or left ventricular hypertrophy. 3. Risk assessment of re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater than 2 years since last imaging study. 4. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction. 5. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization/coronary angiography is not planned. 6. Evaluation of myocardial perfusion viability or function before and more than or equal to 5 years after coronary artery bypass surgery or greater than or equal to 2 years after percutaneous perfusion procedures, unless new clinical signs or symptoms necessitate reevaluation. 7. Quantification and surveillance of myocardial infarction and prognostication in patient with infarction. 8. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery or perioperative management in: o Patients with minor or intermediate clinical risk predictors and poor functional capacity. o Patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity undergoing high risk non-cardiac surgery. The ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery1; provides the following information regarding categorization of surgical risk. They include: o high risk/intermediate risk surgery: aortic and peripheral vascular surgery; intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery and prostate surgery; o low risk surgery: endoscopic procedure, superficial surgery, cataract surgery, breast surgery, ambulatory surgery; o The Guidelines establish poor functional capacity as less than 4 METS; o Utilization of these tests is based on the presence of multiple risk factors, the level of functional capacity, the risk of surgery proposed, and the likelihood that the results of the cardiac testing would change the management. 9. Evaluation of ventricular function in patients with non-ischemic myocardial disease. 10. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker. 11. Evaluation of patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., Adriamycin, Herceptin). Limitations The following are considered not reasonable and necessary and therefore will be denied: 1. Given the limitations of uptake, low photon energy and redistribution, it would not be considered reasonable and necessary for the cardiac blood pool codes and perfusion imaging codes to be performed on the same date of service. 2. It is not considered reasonable and necessary for more than one cardiac blood pool imaging service to be reported on a single date of service. Providers should refer to the applicable Current Procedural Terminology (CPT) Manual to assist with proper reporting of these codes and applicable add-on code(s). 3. All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-physician. (i.e., a Nurse Practitioner [NP] or Physician Assistant [PA]). 4. All stress tests must be performed under the direct supervision of a physician (even in a facility). The nuclear test components must be performed under the general supervision of a physician. Refer to IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80 for information regarding direct supervision. 5. Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, treadmill stress testing, etc.) will be considered screening and denied as not covered by Medicare. 6. Tests that are anticipated to provide information duplicative of another test already performed will be denied as not medically necessary. 7. Tests performed when the results would not be anticipated to influence medical management decisions will be denied as not medically necessary. 8. Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan will be denied as not medically necessary. Refer to NCD 220.12 for more information. 9. Infarct avid scintigraphy will be denied if the diagnosis of myocardial infarction has already been confirmed by enzymes or ECG/EKG. 10. Tests performed unrelated to changes in a patient's signs or symptoms, or for immediate preoperative screening without signs or symptoms will be denied as medically unnecessary. Please see preoperative testing indications above. 11. Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test will be considered medically unnecessary and denied. 12. Tests performed for preoperative evaluation in patients undergoing low-risk surgery will be denied. You can find this rule in the Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L35083) effective October 17, 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.