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 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 
 
Indications and Limitations of Coverage 
 
B. Nationally Covered Indications 
 
The following indications are covered nationally unless otherwise indicated: 
 
    1. Computer analysis of EKGs when furnished in a setting and under the circumstances required for 
coverage of other EKG services. 
    2. EKG services rendered by an IDTF, including physician review and interpretation. Separate physician 
services are not covered unless he/she is the patients attending or consulting physician. 
    3. Emergency EKGs (i.e., when the patient is or may be experiencing a life-threatening event) performed as 
a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the 
time the service is performed or immediately thereafter. 
    4. Home EKG services with documentation of medical necessity. 
    5. Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications 
described below, when performed with equipment meeting the standards described below, subject to the 
limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to 
the physicians service in interpreting the results of such transmissions, including charges for rental of the 
equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME 
separately. Covered uses are to: 
        a. Detect, characterize, and document symptomatic transient arrhythmias; 
        b. Initiate, revise, or discontinue arrhythmic drug therapy; or,         c. Carry-out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only 
if 24-hour coverage is provided, see C.5. below).  
 
Certain uses other than those specified above may be covered if, in the judgment of the local Medicare 
Administrative Contractor (MAC), such use is medically necessary. 
 
Additionally, the transmitting devices must meet at least the following criteria: 
    a. They must be capable of transmitting EKG Leads, I, II, or III; and, 
    b. The tracing must be sufficiently comparable to a conventional EKG. 
 
24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only 
covered if provision is made for such 24-hour attended coverage in the manner described below: 
 
24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician 
or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. 
Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and 
make clinical decisions regarding the patient. The technician should also be instructed as to when and how to 
contact available facilities to assist the patient in case of emergencies. 
 
C. Nationally Non-Covered Indications 
 
The following indications are non-covered nationally unless otherwise specified below: 
 
    1. The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/recording. 
    2. Separate physician services other than those rendered by an IDTF unless rendered by the patients 
attending or consulting physician. 
    3. Home EKG services without documentation of medical necessity. 
    4. Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time of 
service or immediately thereafter. 
    5. 24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI unless 
provision is made for such 24-hour attended coverage in the manner described in section B.5. above. 
    6. Any marketed Food and Drug Administration (FDA)-approved ambulatory cardiac monitoring device or 
service that cannot be categorized according to the framework below. 
 
D. Other 
 
Ambulatory cardiac monitoring performed with a marketed, FDA-approved device, is eligible for coverage if it 
can be categorized according to the framework below. Unless there is a specific NCD for that device or service, 
determination as to whether a device or service that fits into the framework is reasonable and necessary is 
according to local MAC discretion. You can find this information in Medicare's National Coverage 
Determination (NCD): Electrocardiographic Services (20.15) 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.