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 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. 
  
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). 
 
There is no additional reimbursement for a left heart catheterization done for reasons other than hemodynamic 
evaluation or LV angiography required for patient management (i.e., when routinely performed with 
coronary/bypass angiography, electrophysiologic or pacing studies, or endomyocardial biopsies). 
 
 
 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. 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.