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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 state that this is the introduction of a catheter(s) into the right atrium, right ventricle and pulmonary 
artery. It generally includes hemodynamic measurements, and cardiac output determination, and may also 
include, when medically indicated, shunt determinations, and/or blood sampling, and/or hydrogen arrival time 
as part of the procedure. Placement of catheter(s), repositioning, and replacement with other catheters are 
included as part of the procedure. Cannulation of the coronary sinus is included in this procedure. Right heart 
catheterization is a formal diagnostic procedure (with report) performed in a catheterization or other procedure 
suite, as compared to Swan-Ganz catheterization which is generally performed for ongoing monitoring of the 
patient (after the initial diagnostic results are recorded), performed at the bedside, or in an operating room, 
emergency department or other intensive/critical care unit. The results of the Swan-Ganz catheterization may 
be recorded in the progress notes rather than by a formal report. 
 
Right heart catheterization, performed along with left heart catheterization, coronary angiography, or both, is 
seldom medically reasonable and necessary unless one disease process appears to affect both sides of the heart, 
or a different disease process appears to affect each side of the heart. 
 
Indications for Right Heart Catheterization 
Right heart catheterization is indicated to evaluate: 
1. Valvular heart disease; 
2. Congestive heart failure; 
3. Congenital heart disease; 
4. Cor pulmonale; 
5. Pulmonary hypertension; 
6. Intracardiac shunts (including septal rupture) and extracardiac vascular shunts; 
7. Suspected cardiomyopathy or myocarditis; 
8. Endocarditis anticipated to require valvular surgical repair; 
9. Suspected rejection of a transplanted heart; 
10. Suspected pericardial tamponade or constriction. 
 
General Limitations: Cardiac catheterizations for which an overnight stay is anticipated, for routine recovery, should not be billed as 
inpatient services. Furthermore, the routine recovery period should not be billed as observation hours in 
addition to the catheterization unless the patient has sustained untoward complications necessitating the 
continued monitoring. An inpatient or observation stay following a routine outpatient cardiac catheterization 
would be considered not medically necessary and denied. 
 
Limitations for Right Heart Catheterization 
This procedure is performed in a cardiac catheterization laboratory or interventional radiology laboratory, and 
does not include "bedside placement" of a flow directed (Swan-Ganz type) catheter. 
 
There is no reimbursement for a right heart catheterization performed in conjunction with electrophysiologic 
tests or interventions, HIS bundle studies, pacing studies, temporary pacemaker insertion, pulmonary 
angiography, endomyocardial biopsy or interventional cardiac procedures, when routinely performed for 
reasons other than a hemodynamic evaluation. Right heart catheterization with hemodynamic measurements 
done at the same time as these other procedures must be medically necessary based upon the underlying 
cardiovascular pathophysiology. Right heart catheterization for the purpose of monitoring hemodynamic status 
during an electrophysiologic or other interventional cardiac procedure or angioplasty is included in that 
procedure and is not separately reimbursable. 
 
There is no additional reimbursement for leaving a catheter in place for monitoring at the conclusion of a right 
heart catheterization or for the introduction of a Swan-Ganz type catheter at the time of a right heart 
catheterization, or for its subsequent removal. 
 
Right heart catheterization is not indicated for: 
1. Atherosclerotic heart disease without heart failure; or 
2. Angioplasty, electrophysiologic studies or other interventional procedures. 
 
You can find this information Local Coverage Determination (LCD) Cardiac Catheterization and Coronary 
Angiography L33557. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.