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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 MRA is appropriately used to verify the presence of a condition, suspected because of findings from another test (usually an imaging study). For example, a patient who presents with a transient ischemic attack (TIA) should not undergo MRA simply because he might have a lesion which is amenable to surgery. However, if that patient has a carotid bruit and is found by Doppler study to have carotid stenosis, an MRA may be appropriate to evaluate the stenotic section of artery for surgical intervention. Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent insertion. You can find this rule in Local Coverage Determination (LCD): Magnetic Resonance Angiography (MRA) (L34865) - Effective July 1, 2020. The rules say that currently covered indications include using MRA for specific conditions to evaluate flow in internal carotid vessels of the head and neck, peripheral arteries of lower extremities, abdomen and pelvis, and the chest. Coverage is limited to MRA units that have received FDA premarket approval, and such units must be operated within the parameters specified by the approval. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved. You can find this rule in National Coverage Determination (NCD) for Magnetic Resonance Imaging (220.2) - Effective June 3, 2010. The rules say that effective April 15, 2003, studies have proven that MRA is effective for evaluating flow in internal carotid vessels of the head and neck. However, not all potential applications of MRA have been shown to be reasonable and necessary. All of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck: -MRA is used to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses; -MRA is performed on patients with conditions of the head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. These conditions include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis. Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA in specific diseases. The medical records should clearly justify and demonstrate the existence of medical necessity; and -MRA and CA are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests. You can find this rule in National Coverage Determination (NCD) for Magnetic Resonance Imaging (220.2) - Effective June 3, 2010.
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.