Appeal type: unknown
Decision: unknown

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 cardiovascular nuclear imaging is indicated for the following: 
 
- Assessment of the functional and prognostic importance of angina; 
 
- Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by 
drugs, bundle branch block, or left ventricular hypertrophy; 
 
- Assessment of congenital anomalies of coronary arteries; 
 
- Risk assessment or 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; 
 
- 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 are not planned; 
 
- Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other 
re-perfusion procedures; 
 
- Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
 
- Assessment of congenital anomalies of coronary arteries; 
 
- Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/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 "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac 
Surgery" provides this information: 
 
- High risk surgery: aortic and peripheral vascular surgery 
 
- Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck 
surgery, orthopedic surgery, prostate surgery. 
 
- Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory 
surgery 
 
- Poor functional capacity = less than 4 METS 
 
- Clinical risk factors: 
 
            1) history of ischemic heart disease 
            2) history of compensated or prior heart failure 
            3) history of cerebrovascular disease 
            4) diabetes mellitus 
            5) renal insufficiency 
 
- Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional 
capacity, the risk of the surgery 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 a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin). 
 
- First pass studies will be considered medically necessary only when information sought is immediately 
relevant to the management of the patients clinical condition, and has not been previously obtained or likely to 
be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First 
pass studies may be indicated for the assessment and identification of shunts. 
 
- Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of 
myocardial infarction by EKG or enzyme testing. 
 
You can find this information in the Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine 
(L33560). 
 
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.