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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 state that Section 1862(a)(1)(A) of the Social Security Act (SSA) is the statutory basis for denying 
payment for types of care, items, services, and procedures, not excluded by any other statutory clause while 
meeting all technical requirements for coverage, that are determined to be any of the following: 
1. Not generally accepted by the medical community as safe and effective in the setting and for the 
condition for which it is used; 
2. Not proven safe and effective based on peer review or scientific literature; 
3. Experimental; 
4. Not medically necessary for a particular patient; 
5. Furnished at a level, duration, or frequency that is not medically appropriate; 
6. Not furnished in accordance with accepted standards of medical practice; or 
7. Not furnished in a setting appropriate to the patients medical needs and condition. 
Items and services must be established as safe and effective to be considered medically necessary. That is, the 
items and services must be: 
1. Consistent with the symptoms of diagnosis of the illness or injury under treatment; and 
2. Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not 
experimental) and; 
3. Not furnished primarily for the convenience of the patient, the provider or supplier; and 
4. Furnished at the most appropriate level of care that can be provided safely and effectively to the patient. 
Medical devices that are not approved for marketing by the Food and Drug Administration (FDA) are 
considered investigational and are not considered reasonable and necessary under SSA 1862(a)(1)(A). Medicare payment, therefore, may not be made for procedures performed using devices that have not been 
approved for marketing by the FDA unless performed within the context of a clinical trial qualifying under the 
National Coverage Determination (NCD) for Routine Costs in Clinical Trials (310.1) or in approved FDA 
Investigational Device Exemption (IDE) trial. A/B MACs (B) continue to determine if a service is reasonable 
and necessary to treat illness or injury. If a service is not reasonable and necessary to treat illness or injury for 
any reason (including lack of safety and efficacy because it is an experimental procedure, etc.), A/B MACs (B) 
consider the service noncovered notwithstanding the presence of a payment amount for the service in the 
Medicare fee schedule. FDA designation/ determination of a device as 510(k) mean(s) that the device has been 
approved for marketing by the FDA because it is similar to something already on the market that was 
"grandfathered in" by the FDA and therefore these devices are eligible for coverage. 
In addition, items, services, or devices may also be not covered under SSA 1862 (a) (1) (D), (E), or (O). 
 
CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH 
CONTRAST administration, including post-processing of parametric maps with determination of cerebral 
blood flow, cerebral blood volume, and mean transit time Computed Tomographic Perfusion (CTP) (using 
automated post-processing software algorithmic analysis) is medically reasonable and necessary in patients 
with acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior 
circulation evaluated at stroke centers, to aid in selection for endovascular mechanical thrombectomy (EVT) if 
all of the following conditions are fulfilled: 
1. Intracranial internal carotid artery (ICA) OR middle cerebral artery (MCA) occlusion 
2. The medical record documents the patient is being considered for endovascular mechanical 
thrombectomy (EVT) and does not have contraindications to the EVT (based on DAWN or DEFUSE3 
trial criteria) 
3. Treatment (femoral puncture) can be started within 6-24 hours of the last time known to be at 
neurologic baseline 
You can find this rule at the Medicare Local Coverage Determination (LCD)- L35490, Category III Codes. 
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.