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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 implantable (or Insertable Loop) Recorder (ILR) is implanted subcutaneously in a patient's upper left chest and may remain implanted for many months. An ILR is used when syncope is thought to be cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom MLR. The following indications are covered nationally unless otherwise indicated:
1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.
2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.
3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.
4. Home EKG services with documentation of medical necessity.
5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:
a. Detect, characterize, and document symptomatic transient arrhythmias;
b. Initiate, revise, or discontinue arrhythmic drug therapy; or,
c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24-hour coverage is provided, see C.5. below).
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare Administrative Contractor (MAC), such use is medically necessary.
Additionally, the transmitting devices must meet at least the following criteria:
a. They must be capable of transmitting EKG Leads, I, II, or III; and,
b. The tracing must be sufficiently comparable to a conventional EKG.
24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described below:
24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare National Coverage Determination for Electrocardiographic Services, 20.15.
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.