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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 echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function. Stress echocardiography may be indicated in the care of patients with real or suspected ischemic heart disease in the following clinical settings: 1. To detect coronary artery disease in patients presenting with chest pains including atypical chest pains and exertional dyspnea when the suspicion of CAD is high. 2. To assess prognosis and functional capacity in patients following an acute myocardial infarction. 3. To evaluate the extent of exercise induced ischemia in patients who have had a revascularization procedure (PCTA, stent or coronary bypass) or patients who have known CAD disease. 4. In women, stress imaging has been recommended as the "initial test." 5. To evaluate a prior nondiagnostic or abnormal ECG exercise test as a substitute for a nuclear perfusion study. 6. To evaluate patients who are at high risk for myocardial infarction prior to a scheduled major surgical procedure (e.g., aneurysm, vascular surgery, surgeries with large volume shifts, etc) or transplant procedure. 7. To evaluate patients presenting with various arrhythmias (atrial and/or ventricular) or syncope (near or pre), when the suspicion of occult coronary artery disease is high. 8. To evaluate patients when an indicated standard exercise ECG is likely to be non-diagnostic, including patients with an abnormal resting ECG, orthostatic or hyperventilation induced ECG changes, nonspecific ST-T abnormalities due to ventricular hypertrophy drugs or associated intraventricular conduction defect. 9. To assess myocardial viability (hibernating myocardium) for planned revascularization or functional significance of coronary lesions (if not already known) in planning percutaneous transluminal coronary angioplasty. 10. To evaluate cardiomyopathy when the evaluation could reasonably be expected to contribute significant information regarding the patient's condition or treatment plan. 11. To evaluate ventricular dysfunction due to post-transplant rejection when the evaluation could reasonably be expected to contribute significant information regarding the patient's condition or treatment plan. 12. To evaluate congenital heart disease, when stress echocardiography helps to determine systemic and right ventricular function at rest and following stress and the presence of any other structural abnormalities, including valvular lesions that may be accentuated with stress. 13. Additionally the test may combined with Doppler intervention to evaluate exercise hemodynamics in patients with mitral stenosis, mitral regurgitation, pulmonary hypertension, aortic stenosis/regurgitation, prosthetic valves and other conditions where symptoms suggest a more severe impairment than the assessment done at rest. 14. Dobutamine stress echo may be indicated to detect low gradient, low output (aortic stenosis) or clinically silent transplant coronary disease. You can find this rule in Local Coverage Determination (LCD): Transthoracic Echocardiography (TTE) (L33577) - Effective October 1, 2019.
The rules say that transesophageal echocardiography (TTE) is considered medically necessary when there is a reasonable expectation that it will both provide information not available with transthoracic echocardiography or other less invasive forms of imaging and significantly contribute to management decisions regarding treatment of the patient. In order to qualify as a valid echocardiographic service, the study must be done for an accepted clinical indication by a properly trained examiner and must include a permanent record of the findings, data sufficient to support the conclusions and an appropriate interpretation and written report. You can find this rule in Local Coverage Determination (LCD): Transesophageal Echocardiography (TEE) (L33579) - Effective October 1, 2019.
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.