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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 cardiac catheterization is the introduction and positioning of a catheter in the heart to assess 
cardiac function and structure, for diagnosis, treatment planning or to assess therapy. This assessment may 
include the measurement of intracardiac and intra- vascular pressures, obtaining blood samples for blood gas or 
other constituent analysis, determination of cardiac output, injection of contrast for angiography, and 
performing endomyocardial biopsy. The conduct and evaluation of these procedures are then documented and 
interpreted by the physician, in a report. 
 
Cardiac catheterization may be utilized in various clinical situations ranging from those requiring only a right 
heart catheterization to those requiring the performance of right and left heart catheterization with simultaneous 
diagnostic procedures including coronary and bypass angiography, angiography of the cardiac chambers, aortic 
and pulmonary angiography, endomyocardial biopsy, and extra-cardiac angiography. The guidelines in this 
policy outline the indications for coverage of each procedure. 
 
Indications and Limitations for Left Heart Catheterization 
This is the introduction of a catheter(s) into the left ventricle (LV). The catheter may be inserted retrograde 
from the brachial, axillary or femoral artery; by cutdown or percutaneously; or transeptally via a patent 
foramen ovale or by septal puncture; or transapically. The catheterization also includes catheterization of the 
left atrium and aorta when performed with the LV catheterization. It includes all hemodynamic measurements 
(with and without maneuvers and/or infusions or medication), blood sampling and shunt determinations as part 
of the procedure. Placement of multiple catheters and their repositioning or replacement is included in this 
procedure. Injection procedures for selective opacification of cardiac chambers or structures, arteries and 
conduits and the supervision and interpretation of such services are reimbursable as part of all-inclusive codes 
for these services (see Supplementary Instructions Article). 
 
Left heart catheterization is indicated for the diagnosis of, or treatment planning in patients with myocardial 
abnormalities or dysfunction (including ischemic disease, myocarditis, cardiomyopathy, etc), valvular 
dysfunction, intracardiac shunts, congenital heart abnormalities, cardiac trauma, or pericardial tamponade. 
 
 Indications and Limitations for Angiography 
Angiograms of the individual cardiac chambers (atria and ventricles) are indicated for the assessment of mitral 
or tricuspid valve function, ventricular function or morphology (including tumors and clots), suspected 
ventricular aneurysms, intracardiac shunts, congenital heart disease and cardiac trauma. Each procedure (atrial 
or ventricular angiography) may be reimbursed only once regardless of the number of injections of contrast, 
views or actual pictures taken. 
 
Aortography is reimbursable only for diagnoses of aortic root and ascending aorta disease, valvular heart 
disease or congenital heart disease. It is not reimbursable for atherosclerotic heart disease. Angiograms to 
visualize the coronary ostia are included as part of coronary angiography. A diagnosis of rule out (valvular 
lesion) is not reimbursable. 
 
The injection procedure for supravalvular angiography for evaluation of an ascending aortic aneurysm, 
performed during cardiac catheterization, may be covered if it is medically necessary based on the presence of 
signs/symptoms related to an ascending aneurysm or other imaging tests, when providing additional diagnostic 
information. It is not separately payable when performed with a thoracic aortogram. 
 
Coronary angiography is a single procedure which includes arteriograms of all coronary arteries and their 
branches, regardless of the number of vessels selectively catheterized or visualized, with and without the 
administration of diagnostic or therapeutic vasoactive medications. Replacement and repositioning of catheters 
are considered as part of the procedure and are not reimbursable separately. The selective injection procedures 
may be performed without a formal left heart catheterization. Arterial conduit and venous bypass graft 
angiography are reimbursed using the same criteria as are used for the native coronary circulation (reimbursed 
only once regardless of the number of contrast injections, views, or films, or whether medications were 
administered). You can find these rules in the 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.