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 diagnostic tests must be ordered by the physician who is treating the beneficiary and use the 
result in the management of the beneficiarys specific medical problem. Services are deemed medically 
necessary when all of the following conditions are met: 
 
1. Signs/symptoms of ischemia or altered blood flow are present; 
2. The information is necessary for appropriate medical and/or surgical management; 
3. The test is not redundant of other diagnostic procedures that must be performed. Although, in some 
circumstances, non-invasive vascular tests are complimentary, such as MRA and duplex, where the latter may 
confirm an indeterminate finding or demonstrate the physiologic significance of an anatomic stenosis 
(especially in the carotids and lower extremity arterial system). 
 
You can find this rule in the Local Coverage Determination (LCD) - Non-Invasive Cerebrovascular Studies 
(L35753) - Effective October 1, 2021. 
 
The rules say that testing methods that include (real-time) duplex scans and Doppler ultrasound waveform with 
spectral analysis are covered for the following: 
 
1. Cervical bruits. 
2. Amaurosis fugax (transient monocular blindness). 
3. Focal cerebral or ocular transient ischemic attacks. 
4. Drop attack or syncope is only covered with vertebrobasilar or bilateral carotid artery disease as suggested 
by the patients history. If an echocardiogram is negative for a cardiac or cardiac valvular cause, it may be 
medically appropriate to perform extracranial arteries studies for the drop attack or syncope. 
5. Subclavian steal syndrome (symptoms usually associated with it are a bruit in the subclavian fossa, unequal 
radial pulses, arm claudication following minimal exercise, and a difference of 20 mm Hg or more between the 
systolic blood pressures in the arms). 
6. Evaluation of blunt or penetrating neck trauma or injury to the carotid artery. 
7. Follow-up after a carotid endarterectomy or carotid stenting. 
8. Suspected aneurysm of the carotid artery. Patients with swelling of the neck particularly if occurring post 
carotid endarterectomy. 
9. Re-evaluation of existing carotid stenosis. 
10. Evaluation of pulsatile neck mass. 
11. Preoperative evaluation of patient scheduled for major cardiovascular surgical procedure when there is 
evidence of systemic atherosclerosis. 
12. Preoperatively validate the degree of carotid stenosis of patients whose previous duplex scan revealed a 
greater than 60% diameter reduction. The duplex is only covered when the surgeon questions the validity of the 
previous study and the repeat test is performed in lieu of a carotid arteriogram. 
13. Ocular micro embolism (optic nerve/retinal arterial - Hollenhorst plaques/ocular). 
14. Evaluation of suspected dissection. 
15. Recent stroke (defined as less than six months) for determining the cause of the stroke. 
16. Vasculitis involving the extracranial carotid arteries. 
17. Diagnosis of carotid disease on medical management and cerebrovascular symptoms are reocurring 
18. Pulsatile tinnitus with other symptoms involving the cardiovascular system. 
 
You can find this rule in the Local Coverage Determination (LCD) - Non-Invasive Cerebrovascular Studies 
(L35753) - Effective October 1, 2021. 
 
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.