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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 echocardiography is indicated in the evaluation of derangements of valvular, myocardial 
and pericardial structure and function.  
 
    1. Echocardiography performed for screening purposes is not covered. Screening includes testing performed 
on patients who present with risk factors (including the risk factor as having a positive family history, e.g., 
familial history of Marfan's disease). A screening service for high-risk patients is considered good medical 
practice but is not covered by Medicare. When the result of the test is abnormal, subsequent services may be 
billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though 
the result of the screening test may be a covered condition. 
 
The following indications (#2-15) are deemed to be not medically necessary and are therefore not 
reimbursable: 
 
2. Routine (yearly) evaluation of asymptomatic patients with corrected ASD, VSD or PDA more than one year 
after successful correction. 
 
3. Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no 
change in clinical status. 
 
4. Routine (yearly) re-evaluation of an asymptomatic patient with mild native aortic stenosis or mild-moderate 
native mitral stenosis and no change in clinical status. 
 
5. Routine (yearly) re-evaluation of native valvular regurgitation in an asymptomatic patient with mild 
regurgitation, no change in clinical status and normal left ventricular size. 
 
6. Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular 
dysfunction and no change in clinical status. 
 
7. Routine (yearly) re-evaluation of patients with heart failure (systolic or diastolic) in whom there is no change in clinical status. 
 
8. Routine (yearly) evaluation of hypertrophic cardiomyopathy in a patient with no change in clinical status. 
 
9. Patients who have isolated APC or VPC without other evidence of heart disease. 
 
10. Evaluation of LV function with prior ventricular function within the past year with normal (such as prior 
echocardiogram, left ventriculogram, SPECT, cardiac MRI) in patients in whom there has been no change in 
clinical status. 
 
11. Initial evaluation of patient with suspected pulmonary embolism in order to establish diagnosis. 
 
12. Evaluation of native and/or prosthetic valves in patients with transient fever but without evidence of 
bacteremia or new murmur. 
 
13. Re-evaluation of a patient with known hypertensive heart disease without a change in clinical status. 
 
14. Routine evaluation of patients with systemic hypertension without suspected hypertensive heart disease. 
 
15. Evaluation of a patient with atrial fibrillation/flutter for left atrial thrombus or spontaneous contrast when a 
decision has been made to anticoagulate and not to perform cardioversion. 
 
You can find this information Local Coverage Determination (LCD) Transthoracic Echocardiography (TTE) 
L33577. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.