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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 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).
The rules say that 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.
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.
Another patient may present with a headache; it is not appropriate to proceed directly to MRA to rule out the
possibility of an intracranial aneurysm. However, if that patient was found to have a clinically significant
amount of blood in the cerebrospinal fluid, or the patient demonstrated signs and symptoms strongly suggesting
an unruptured intracranial aneurysm, an MRA (or cerebral angiogram) may be appropriate. An MRA is not
considered medically necessary for screening asymptomatic patients for intracranial aneurysms.
Please note that the anticipated surgery may be a percutaneous procedure such as carotid angioplasty with stent
insertion.
You can find this information in the Local Coverage Determination (LCD): Magnetic Resonance Angiography
(MRA) (L33633).
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.