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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 CFR 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 411.15 and 411.15(o). 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: - Assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent symptoms. - 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. - 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. - Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction. - Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization/coronary angiography is not planned. - 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. - Quantification and surveillance of myocardial infarction and prognostication in patient with infarction. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery or perioperative management in: - Patients with minor or intermediate clinical risk predictors and poor functional capacity. - 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: - 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; - low risk surgery: endoscopic procedure, superficial surgery, cataract surgery, breast surgery, ambulatory surgery; - The Guidelines establish poor functional capacity as less than 4 METS; - 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. - Evaluation of ventricular function in patients with non-ischemic myocardial disease. - 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. - Evaluation of patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., Adriamycin, Herceptin). You can find this information in the Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L35083).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.