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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 since Gruentzigs 1979 report of coronary balloon angioplasty, percutaneous transluminal 
coronary interventions have substantively altered the management of patients with symptomatic arteriosclerotic 
heart disease. Balloon angioplasty rapidly expanded from single to multiple vessels and from simple to 
complex anatomic substrates. Transluminal interventions now encompass balloon dilation (PTCA), a variety of 
atherectomy devices, high pressure and biologic/polymer coated stents as well as transluminal thrombectomy. 
Additionally, intracoronary ultrasound is often employed to assess the efficacy of these interventions. In 
addition to medical therapy and coronary bypass surgery, percutaneous coronary intervention has emerged as a 
primary option for the management of patients with acute coronary syndromes and selected patients with 
chronic angina. Percutaneous coronary intervention (PCI) may be indicated in the management of : 
 
    patients with acute coronary syndrome (e.g. acute myocardial infarction, unstable angina) 
    patients with a history of significant obstructive atherosclerotic disease 
    patients with restenosis of a coronary artery previously treated with intracoronary stent or other 
revascularization procedure 
    patients with chronic angina 
    patients with silent ischemia 
 
Intracoronary ultrasound may be separately covered when needed to assess the extent of coronary stenosis if 
equivocal on angiography, or when needed to assess the patency and integrity of a coronary artery post-
intervention. Alternatively, intravascular Doppler velocity and/or pressure derived coronary flow reserve 
measurement may be performed to assess the degree of stenosis within a vessel. A diagnostic cardiac 
catheterization to assess the nature of the lesion(s) prior to the intervention is a covered service. The diagnostic 
cardiac catheterization may be performed at any time prior to the PCI, including the same day as the PCI. 
 
Performance of a diagnostic cardiac catheterization and interventional procedure on the same day is 
increasingly the standard of practice. While there may be reasons for delaying the interventional procedure 
(e.g., transfer from a community hospital to a tertiary center, excessive dye load, further treatment planning or 
evaluation of angiography, etc.), it is recommended that both procedures be performed during the same 
encounter when medically appropriate. Separation of these procedures for the purpose of circumventing the 
multiple surgery pricing, or for the convenience of physician or hospital scheduling, is considered an 
inappropriate practice and may subject the services to review and denial for medical necessity. The decision to 
stage these procedures is deferred to the judgment of the interventional cardiologist and individualized only to 
the clinical needs of the patient. (e.g., dye load already received, need to correlate findings with other test results, etc.). Reasons for delaying indicated intervention should be documented in the medical record. Unless 
there is a new clinical event or change in symptomatology, examination or other test results, a repeat diagnostic 
catheterization service within three months of a previous diagnostic catheterization, and prior to completion of 
the staged intervention is generally not reimbursable and is considered not to be reasonable and necessary. 
 
Angiography during the procedure, used to monitor the course of the intervention, is considered part of the PCI 
and is not separately billable to Medicare. Diagnostic angiography may be separately payable in situations 
where no previous catheter-based coronary angiography study is available, or a previous study is no longer 
adequate due to changes in the patients condition. Intracoronary injections of drugs during diagnostic or 
therapeutic procedures are considered to be part of the procedure and are not separately reimbursable. 
 
Percutaneous vascular closure devices (PVCD) may be used to facilitate closure of an arterial puncture site 
after angiography, cardiac catheterization and interventional cardiology procedures in addition to or in place of 
manual compression, use of a mechanical clamp or a sandbag, or a combination of these methods. These 
services are inherent to the invasive procedure and are not separately payable. You can find these rules in the 
Local Coverage Determination (LCD) Percutaneous Coronary Intervention L33623. 
 
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.