Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has pre-approve the electrocardiogram. We decided that the Plan does not have pre-
approve the testing of autonomic nervous system function.  
 
You asked the Plan pre-approve testing of autonomic nervous system function (95924, 95923) with 
electrocardiogram (93040). You say that you have severe pain in your legs due to inflamed veins. You say that 
this prevents you from moving freely sometimes. You also say that you have to take four pills a day to reduce 
the pain. The Plan says that the provider indicates this is for screening purposes. 
 
We decided that the Plan has pre-approve the electrocardiogram.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request pre-approve the electrocardiogram. Our reviewer says 
that the requested electrocardiogram is medically necessary. Our physician reviewer found the provided 
documentation indicates you have been having difficulty moving. Therefore, the reviewer found that the 
electrocardiogram is medically reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrocardiogram have been met. Therefore, we decided that the Plan has 
pre-approve the electrocardiogram.  
 
We also decided that the Plan does not have pre-approve the testing of autonomic nervous system 
function. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request pre-approve the testing of autonomic nervous system 
function. Our reviewer says that the requested testing of autonomic nervous system function is not medically 
necessary. Our physician reviewer found the provided documentation does not indicate a clear need or 
significance for the autonomic testing. Therefore, the reviewer found that the autonomic testing is not 
medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing of autonomic nervous system function have not been met. Therefore, 
we decided that the Plan does not have pre-approve the testing of autonomic nervous system function. 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.