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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 say that peripheral artery studies may be considered medically necessary if the following signs and 
symptoms are present: 
- Claudication of such severity that it interferes significantly with the patient's occupation or lifestyle, or 
claudication with inability to stress the patient; 
- Rest pain (typically including the forefoot), usually associated with absent pulses, which becomes 
increasingly severe with elevation and diminishes with placement of the leg in a dependent position; 
- Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of 
the extremity occurring in the absence of pulses; 
- Aneurysmal disease; 
- Evidence of thromboembolic events; 
- Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures); 
and/or 
- Follow-up of grafts or other vascular intervention 
You can find this information in Local Coverage Determination (LCD): Non-Invasive Vascular Studies 
(L33627). 
 
The rules say that syndromes of autonomic dysfunction which require formal autonomic function testing are 
relatively rare. Generally, only after excluding more common causes of autonomic signs or symptoms (e.g., 
hypotension, hyperhidrosis, and orthostatic tachycardia) may formal autonomic testing be indicated to exclude or confirm rarer autonomic disorders. Autonomic function testing is covered as reasonable and necessary when 
used as a diagnostic tool to evaluate symptoms indicative of vasomotor instability and the ANS testing is 
directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant 
medical decision making for one of the following indications: 

1. To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a 
progressive autonomic neuropathy. 
2. To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy. 
3. To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss 
of consciousness. 
4. To evaluate inadequate response to beta blockade in vasodepressor syncope. 
5. To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber 
neuropathy in order to diagnose the condition. 
6. To differentiate the cause of postural tachycardia syndrome. 
7. To evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic 
failure. 
8. To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in 
clinical exam. 
9. To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient. 
10. To evaluate and treat patients with recurrent unexplained syncope or demonstrate autonomic failure, 
after more common causes have been excluded by other standard testing. 

You can find this information in Local Coverage Determination (LCD): Autonomic Function Testing 
(L36236). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.