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 Non-invasive vascular studies are considered medically necessary if the ordering physician has reasonable expectation that their outcomes will potentially impact the clinical management of the patient. Services are deemed medically necessary when the following conditions are met: Significant signs/symptoms of arterial or venous disease are present; and/or; The information is necessary for appropriate medical and/or surgical management; and/or; The test is not redundant of other diagnostic procedures that must be performed. In general, non-invasive studies of the arterial system are utilized when invasive correction is contemplated or when vessels are being harvested for potential use as grafts. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. Extracranial Arterial Studies: Covered cerebrovascular arterial study testing methods include (real-time) duplex scans; and Doppler ultrasound waveform with spectral analysis. Non-covered/non-reimbursed methods include testing methods that have not been found to be useful based on authoritative technological assessments or that are included as part of the physical examination. Indications: Cerebrovascular arterial studies may be considered medically necessary if one or more of the following signs and symptoms are present: Asymptomatic or symptomatic cervical bruits; Amaurosis fugax; Focal cerebral or ocular transient ischemic attacks (including but not limited to): < >localizing symptoms, e.g., sensory loss; and/or weakness of one side of the face; and/or slurred speech; and/or weakness of a limb; Syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as suggested by medical history; Recent history of a previous neurologic or cerebrovascular event; Before major cardiac and vascular surgery when a bruit is noted, there is history of previous neurologic or cerebrovascular event, or there is documented clinical suspicion of extracranial carotid occlusion and the rationale for the study is included in the chart; After carotid endarterectomy (outside the global period), or follow-up of previously documented stenoses; Pulsatile neck mass; Evaluation of blunt or penetrating neck trauma; Ocular microembolism; Limitations: Studies may not be considered medically necessary if performed for the following signs and symptoms: Drop attack or syncope are rare indications usually seen with vertebrobasilar or bilateral carotid artery disease. Dizziness is not a typical indication unless associated with other localizing signs or symptoms. However, episodic dizziness with symptom characteristics typical of transient ischemic attacks may indicate medical necessity, especially when other more common sources, e.g., postural hypotension or transiently decreased cardiac output as demonstrated by cardiac event monitoring, have been previously excluded; and/or; Headaches (including migraines). You can find this information in Medicare's Local Coverage Determination (LCD): Non-Invasive Vascular Studies (L33627).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.