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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 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 right atrium, right ventricle and pulmonary artery. It generally 
includes hemodynamic measurements, and cardiac output determination, and may also include, when medically 
indicated, shunt determinations, and/or blood sampling, and/or hydrogen arrival time as part of the procedure. 
Placement of catheter(s), repositioning, and replacement with other catheters are included as part of the 
procedure. Cannulation of the coronary sinus is included in this procedure. Right heart catheterization is a 
formal diagnostic procedure (with report) performed in a catheterization or other procedure suite, as compared 
to Swan-Ganz catheterization which is generally performed for ongoing monitoring of the patient (after the 
initial diagnostic results are recorded), performed at the bedside, or in an operating room, emergency 
department or other intensive/critical care unit. The results of the Swan-Ganz catheterization may be recorded 
in the progress notes rather than by a formal report. 
 
Right heart catheterization, performed along with left heart catheterization, coronary angiography, or both, is 
seldom medically reasonable and necessary unless one disease process appears to affect both sides of the heart, 
or a different disease process appears to affect each side of the heart. 
 
Right heart catheterization is indicated to evaluate: 
1. Valvular heart disease; 
2. Congestive heart failure; 
3. Congenital heart disease; 
4. Cor pulmonale; 5. Pulmonary hypertension; 
6. Intracardiac shunts (including septal rupture) and extracardiac vascular shunts; 
7. Suspected cardiomyopathy or myocarditis; 
8. Endocarditis anticipated to require valvular surgical repair; 
9. Suspected rejection of a transplanted heart; 
10. Suspected pericardial tamponade or constriction. 
 
Cardiac catheterizations for which an overnight stay is anticipated, for routine recovery, should not be billed as 
inpatient services. Furthermore, the routine recovery period should not be billed as observation hours in 
addition to the catheterization unless the patient has sustained untoward complications necessitating the 
continued monitoring. An inpatient or observation stay following a routine outpatient cardiac catheterization 
would be considered not medically necessary and denied. 
 
This procedure is performed in a cardiac catheterization laboratory or interventional radiology laboratory and 
does not include "bedside placement" of a flow directed (Swan-Ganz type) catheter. 
 
Right heart catheterization is not indicated for: 
1. Atherosclerotic heart disease without heart failure; or 
2. Angioplasty, electrophysiologic studies or other interventional procedures. 
 
You can find this rule 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.