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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 state 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. 
 
General Limitations: 
 
A referral must be on record for each non-invasive study performed. A referral for one type of study does not 
qualify as a referral for all tests. 
 
Non-invasive vascular studies are considered medically necessary only if the outcome will potentially impact 
the clinical course of the patient. Non-invasive venous studies may be helpful in in assessing the adequacy of 
venous conduits, prior to various vascular interventions. However, if the medical records suggest the patient is 
proceeding directly to angiography or another more potentially definitive study, and the specific rationale for 
the non-invasive studies is not noted, they will be considered as not medically necessary.  
 
Non-invasive vascular studies include patient care required to perform the studies, supervision of the studies, 
and interpretation of study results with hard copy output or imaging. Digital storage of imaging is acceptable. It may be necessary to perform simultaneous arterial and venous studies during the same encounter. 
Documentation must be available to support the medical necessity for both studies. 
 
It is rarely necessary to perform cerebrovascular and upper extremity studies on the same day. Clinical 
suspicion of extra-cranial carotid disease as justification for pre-operative Doppler studies must be supported in 
the medical records. 
Transcranial Doppler (TCD) Studies 
 
Transcranial Doppler (TCD) studies of the intracranial arteries and transcranial duplex imaging of extracranial 
arteries are approved methods of testing. The presence, location, and extent of disease can be evaluated by 
utilizing directional pulsed Doppler to estimate flow velocities and assess intracranial vessel hemodynamics 
and physiology. 
 
Indications: 
 
TCD studies are allowed for the following: 
 Detection and evaluation of the hemodynamic effects of severe stenosis or occlusion of the extracranial 
(greater than or equal to 60% diameter reduction) and major basal intracranial arteries (greater than or 
equal to 50% diameter reduction); 
 Detection and serial evaluation of cerebral vasospasm complicating subarachnoid hemorrhage; 
 Evaluation of intracranial hemodynamic abnormalities in patients with suspected brain death; 
 Intraoperative and perioperative monitoring of intracranial flow velocity and hemodynamic patterns 
during carotid endarterectomy, (although the professional component could only be reimbursed if it is 
provided during the operative procedure by a physician that is not a member of the operating team); 
 Evaluation of cerebral embolization; and/or 
 Assessing hemodynamic effects, patterns, and extent of collateral circulation in patients with known 
regions of severe stenosis or occlusion when necessary to care for the patient; and 
 Assessing stroke risk in children aged two to sixteen with homozygous sickle cell disease; and 
 As an alternative to an echocardiogram to detect residual right to left shunting after repair/closure of an 
intracardiac or intrapulmonary shunt. 
Multiple cerebrovascular procedures may be allowed during the same encounter given the physician/provider 
can demonstrate medical necessity as documented in the patients medical record. For example, physiologic 
studies and a duplex scan are allowed on the same date of service given the provider is able to document 
medical necessity, e.g., greater than or equal to 50% stenosis on duplex scan or significant symptoms as 
demonstrated by the indications for the study. 
 
Limitations: 
 
TCD studies are not indicated for: 
 Evaluation of brain tumors; 
 Assessment of familial and degenerative disease of the cerebrum, brainstem, cerebellum, basal ganglia 
and motor neurons; 
 Evaluation of infectious and inflammatory conditions; 
 Psychiatric disorders; and/or 
 Epilepsy. 
Transcranial Doppler (TCD) is considered investigational and not medically necessary for the following 
indications:  Assessing patients with migraine; 
 Monitoring during cardiopulmonary bypass and other cerebrovascular and cardiovascular interventions, 
and surgical procedures (except during carotid endarterectomy, as noted above); 
 Evaluation of patients with dilated vasculopathies such as fusiform aneurysms; 
 Assessing autoregulation, physiologic, and pharmacological responses of cerebral arteries; and/or 
 Evaluating children with various vasculopathies, such as moyamoya disease and neurofibromatosis. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33627: Non-Invasive Vascular 
Studies. 
 
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.