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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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: 
 
    To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a 
progressive autonomic neuropathy. 
    To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy. 
    To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of 
consciousness. 
    To evaluate inadequate response to beta blockade in vasodepressor syncope. 
    To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber 
neuropathy in order to diagnose the condition. 
    To differentiate the cause of postural tachycardia syndrome. 
    To evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure. 
    To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam. 
    To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient. 
    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 rule in the Local Coverage Determination (LCD): Autonomic Function Testing  (L36236). 
 
The rules say that non-invasive vascular studies are considered medically necessary if the ordering physician 
has reasonable expectation that their outcomes will potentially impact the clinical management of the patient. 
Services are deemed medically necessary when the following conditions are met: 
 
    Significant signs/symptoms of arterial or venous disease are present; and/or 
    The information is necessary for appropriate medical and/or surgical management; and/or 
    The test is not redundant of other diagnostic procedures that must be performed. 
 
In general, non-invasive studies of the arterial system are utilized when invasive correction is contemplated or 
when vessels are being harvested for potential use as grafts. It is the responsibility of the physician/provider to 
ensure the medical necessity of procedures and documentation of such in the medical record. 
 
Peripheral Arterial Examinations  
 
Covered peripheral arterial study testing methods include duplex scans; Doppler waveform or spectral analysis; 
volume, impedance or strain gauge plethysmography; and transcutaneous oxygen tension measurement. 
 
Non-covered peripheral arterial study testing methods include thermography, mechanical oscillometry, 
inductance or capacitance plethysmography, photoelectric plethysmography, differential plethysmography, and 
light reflective rheography. 
 
Indications: 
 
Non-invasive peripheral arterial examinations, performed to establish the level and/or degree of arterial 
occlusive disease, are medically necessary if (1) clinical evidence of limb ischemia is present and (2) the 
patient is a candidate for invasive/surgical therapeutic interventions. Acute ischemia is often characterized by 
the sudden onset of severe pain, coldness, numbness and pallor of the extremity. Chronic ischemia can be 
manifested by intermittent claudication, pain at rest, diminished pulse, ulceration, and gangrene. 
 
A routine history and physical examination, which includes ankle/brachial indices (ABIs), can readily 
document the presence or absence of ischemic disease in the majority of cases. An ABI is not a reimbursable 
procedure by itself; rather, ABI may be reimbursed when derived from a more comprehensive procedure which 
includes a permanent chart copy of the measured pressures and waveforms in the examined vessels. 
 
An ABI should be abnormal, e.g., <0.9 at rest, and accompanied by other appropriate indications before 
proceeding to additional studies. 
 
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 patients 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 
 
Pre-surgical conduit assessment of the upper extremity/radial artery(ies) may be performed prior to use in 
coronary artery bypass grafting (CABG) or as other arterial conduits.You can find this rule in the Local 
Coverage Determination (LCD): Non-Invasive Vascular Studies (L33627). 
 
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.