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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 covered peripheral arterial study testing methods include duplex scans; Doppler waveform 
or spectral analysis; volume, impedance or strain gauge plethysmography; and transcutaneous oxygen tension 
measurement. 
 
Non-covered peripheral arterial study testing methods include thermography, mechanical oscillometry, 
inductance or capacitance plethysmography, photoelectric plethysmography, differential plethysmography, and 
light reflective rheography. 
 
Indications: 
 
Non-invasive peripheral arterial examinations, performed to establish the level and/or degree of arterial 
occlusive disease, are medically necessary if (1) significant signs and/or symptoms of possible limb ischemia 
are present and (2) the patient is a candidate for invasive/surgical therapeutic interventions. Acute ischemia is 
characterized by the sudden onset of severe pain, coldness, numbness and pallor of the extremity. Chronic 
ischemia can be manifested by intermittent claudication, pain at rest, diminished pulse, ulceration, and 
gangrene. 
 
A routine history and physical examination, which includes ankle/brachial indices (ABIs), can readily 
document the presence or absence of ischemic disease in the majority of cases. It is not medically necessary to 
proceed beyond the physical examination for minor signs and symptoms such as hair loss, absence of a single 
pulse, relative coolness of a foot, shiny thin skin, or lack of toe nail growth unless related signs and/or 
symptoms are present which are severe enough to require possible invasive intervention. 
 
An ABI is not a reimbursable procedure by itself; rather, ABI may be reimbursed when derived from a more 
comprehensive procedure which includes a permanent chart copy of the measured pressures and waveforms in 
the examined vessels. An ABI should be abnormal, e.g., and must be accompanied by another appropriate 
indication before proceeding to more sophisticated or complete studies, except in patients with severe diabetes 
or uremia resulting in medial calcification as demonstrated by artifactually elevated ankle blood pressure. 
 Peripheral artery studies may be considered medically necessary if the following signs and symptoms are 
present:  
 Claudication of such severity that it interferes significantly with the patients occupation or lifestyle, or 
claudication with inability to stress the patient; 
 Rest pain (typically including the forefoot), usually associated with absent pulses, which becomes 
increasingly severe with elevation and diminishes with placement of the leg in a dependent position; 
 Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of 
the extremity occurring in the absence of pulses; 
 Aneurysmal disease; 
 Evidence of thromboembolic events; 
 Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures); 
and/or 
 Follow-up of grafts or other vascular intervention 
Pre-surgical conduit assessment of the upper extremity/radial artery(ies) may be performed prior to use in 
coronary artery bypass grafting (CABG) or as other arterial conduits. 
 
Limitations: 
 
Peripheral artery studies may not be considered medically necessary if only the following signs and symptoms 
are present:  
 Continuous burning of the feet (considered to be a neurologic symptom); 
 Leg pain, nonspecific (M79.606) and pain in limb (M79.669) as single diagnoses are too general to 
warrant further investigation unless they can be related to other signs and symptoms; 
 Edema rarely occurs with arterial occlusive disease unless it is in the immediate postoperative period, in 
association with another inflammatory process or in association with rest pain; and/or 
 Absence of pulses in minor arteries, e.g., dorsalis pedis or posterior tibial, in the absence of symptoms. 
The absence of pulses is not an indication to proceed beyond the physical examination unless it is 
related to other signs and/or symptoms. 
Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic 
studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease, if the 
physician/provider can document medical necessity in the patients medical record. 
 
In general, non-invasive studies of the arterial system are to be utilized when invasive correction is 
contemplated or severity of findings dictate non-invasive study follow-up, but not for following non-invasive 
medical treatment regimens. The latter may be followed with physical findings and/or progression or relief of 
signs and/or symptoms. Screening of the asymptomatic patient is not covered by Medicare. 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L34045, 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.