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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 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 the indications for Myocardial Perfusion Imaging are:

1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of myocardial
infarction (MI), if the diagnosis is established by other means. In selected patients, imaging is appropriate in
the assessment of:

o Disease severity
o Risk assessment and/or prognosis
o Efficacy of acute reperfusion therapy
o Evidence of myocardial salvage
o Suspected infarction when the combination of history and other tests is not diagnostic.

2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of unstable
angina only when the combination of history and other tests is not diagnostic. In selected patients, imaging is
appropriate for:

o Identification of ischemia in the distribution of a known lesion or in remote areas
o Identification of the severity/extent of disease in patients with medically unstable angina or
ongoing ischemia
o Measurement of left ventricular function (LVF).

3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of
CAD and is covered in these situations:

o Diagnosis of CAD, especially in patients with atypical chest pain
o Evaluation of abnormal or suspected false positive stress ECG
o Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and
ventricular arrhythmia
o Assessment of myocardial viability after revascularization or medical management
o Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing
ischemia, if unknown
o Evaluation of suspected or known CAD prior to high-risk surgical procedure
o Identification of the presence, location, extent, and severity of myocardial ischemia
o Assessment of drug therapy
o Assessment of symptoms suggesting restenosis following PTCA
o Assessment of symptoms suggesting ischemia following Coronary Artery Bypass Graft (CABG)
o Follow up of symptomatic ischemic heart disease

4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or
suspected CHD. Selected patients may benefit from MPI when assessing for:

o Diagnosis of anomalies of the coronary circulation
o Kawasaki's disease

5. Post-transplant cardiac disease

o Assessment of coronary arteriopathy
o Evaluation for ventricular dysfunction with post-transplant rejection

You can find this information in the Local Coverage Determination (LCD): Cardiac Radionuclide Imaging
(L33457).

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.