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 state that ultrasound diagnostic procedures are listed below and are divided into two categories.
Medicare coverage is extended to the procedures listed in Category I.

Periodic claims review by the A/Medicare Administrative Contractor (A/MAC) medical consultants should be
conducted to ensure that the techniques are medically appropriate and the general indications specified in these
categories are met. Techniques in Category II are considered experimental and should not be covered at this
time.

Indications and Limitations of Coverage

B. Nationally Covered Indications

Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and
nuclear medicine diagnostic technique)

Echoencephalography, (Diencephalic Midline) (A-Mode).
Echoencephalography, Complete (Diencephalic Midline and Ventricular Size).
Ocular and Orbital Echography (A-Mode).
Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an
artificial lens (pseudophakoi) following cataract surgery.
Ocular and Orbital Sonography (B-Mode).
Echocardiography, Pericardial Effusion (M-Mode).
Pericardiocentesis, by Ultrasonic Guidance.
Echocardiography, Cardiac Valve(s) (M-Mode).
Echocardiography, Complete (M-Mode).
Echocardiography, limited (e.g., follow-up or limited study) (M-Mode).
Pleural Effusion Echography.
Thoracentesis, by Ultrasonic Guidance.
Abdominal Sonography, complete survey study (B-Scan).
Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan).
Abdominal Sonography is not synonymous with ultrasound examination of individual organs.
Renal Cyst Aspiration, by Ultrasonic Guidance.
Renal Biopsy, by Ultrasonic Guidance.
Pancreas Sonography (B-Scan).
Pancreatic Sonography has proven effective in diagnosing pseudocysts.
Spleen Sonography (B-Scan).
Abdominal Aorta Echography (A-Mode).
Abdominal Aorta Sonography (B-Scan).
Retroperitoneal Sonography (B-Scan).
Retroperitoneal Sonography does not include planning of fields for radiation therapy.
Urinary Bladder Sonography (B-Scan).
Urinary bladder Sonography does not include staging of bladder tumors.
Pregnancy Diagnosis Sonography (B-Scan).
Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan).
Fetal Growth Rate Sonography (B-Scan).
Placenta Localization Sonography (B-Scan).
Pregnancy Sonography, Complete (B-Scan).
Molar Pregnancy Diagnosis Sonography (B-Scan).
Ectopic Pregnancy Diagnosis Sonography (B-Scan).
Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus).
Intrauterine Contraceptive Device Sonography (B-Scan).
Pelvic Mass Diagnosis Sonography (B-Scan).
Amniocentesis, by Ultrasonic Guidance.
Arterial Flow Study, Peripheral (Doppler).
Venous Flow Study, Peripheral (Doppler).
Arterial Aneurysm, Peripheral (B-Scan).
Radiation Therapy Planning Sonography (B-Scan).
Thyroid Echography (A-Mode).
Thyroid Sonography (B-Scan).
Breast Echography (A-Mode).
Breast Sonography (B-Scan).
Hepatic Sonography (B-Scan).
Gallbladder Sonography.
Renal Sonography.
Two-Dimensional Echocardiography (B-Mode).
Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients
with a need for intra-operative fluid optimization

You can find this information in the National Coverage Determination (NCD) Ultrasound Diagnostic
Procedures (220.5).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.