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Decision: unknown

 
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 Nationally Covered Indications 
Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and 
nuclear medicine diagnostic technique) 
 Echoencephalography, (Diencephalic Midline) (A-Mode). 
 Echoencephalography, Complete (Diencephalic Midline and Ventricular Size). 
 Ocular and Orbital Echography (A-Mode). 
 Covered procedures include efforts to determine the suitability of aphakic patients for implantation of 
an artificial lens (pseudophakoi) following cataract surgery. 
 Ocular and Orbital Sonography (B-Mode). 
 Echocardiography, Pericardial Effusion (M-Mode). 
 Pericardiocentesis, by Ultrasonic Guidance. 
 Echocardiography, Cardiac Valve(s) (M-Mode). 
 Echocardiography, Complete (M-Mode). 
 Echocardiography, limited (e.g., follow-up or limited study) (M-Mode). 
 Pleural Effusion Echography. 
 Thoracentesis, by Ultrasonic Guidance. 
 Abdominal Sonography, complete survey study (B-Scan). 
 Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan). 
 Abdominal Sonography is not synonymous with ultrasound examination of individual organs. 
 Renal Cyst Aspiration, by Ultrasonic Guidance. 
 Renal Biopsy, by Ultrasonic Guidance. 
 Pancreas Sonography (B-Scan). 
 Pancreatic Sonography has proven effective in diagnosing pseudocysts. 
 Spleen Sonography (B-Scan). 
 Abdominal Aorta Echography (A-Mode). 
 Abdominal Aorta Sonography (B-Scan). 
 Retroperitoneal Sonography (B-Scan). 
 Retroperitoneal Sonography does not include planning of fields for radiation therapy. 
 Urinary Bladder Sonography (B-Scan). 
 Urinary bladder Sonography does not include staging of bladder tumors. 
 Pregnancy Diagnosis Sonography (B-Scan). 
 Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan). 
 Fetal Growth Rate Sonography (B-Scan).  Placenta Localization Sonography (B-Scan). 
 Pregnancy Sonography, Complete (B-Scan). 
 Molar Pregnancy Diagnosis Sonography (B-Scan). 
 Ectopic Pregnancy Diagnosis Sonography (B-Scan). 
 Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus). 
 Intrauterine Contraceptive Device Sonography (B-Scan). 
 Pelvic Mass Diagnosis Sonography (B-Scan). 
 Amniocentesis, by Ultrasonic Guidance. 
 Arterial Flow Study, Peripheral (Doppler). 
 Venous Flow Study, Peripheral (Doppler). 
 Arterial Aneurysm, Peripheral (B-Scan). 
 Radiation Therapy Planning Sonography (B-Scan). 
 Thyroid Echography (A-Mode). 
 Thyroid Sonography (B-Scan). 
 Breast Echography (A-Mode). 
 Breast Sonography (B-Scan). 
 Hepatic Sonography (B-Scan). 
 Gallbladder Sonography. 
 Renal Sonography. 
 Two-Dimensional Echocardiography (B-Mode). 
 Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative 
patients with a need for intra-operative fluid optimization 
Nationally Non-Covered Indications 
Category II - (Clinical reliability and efficacy not proven): 
 B-Scan for atherosclerotic narrowing of peripheral arteries. 
Other 
Uses for ultrasound diagnostic procedures not listed in Category I or II above are left to local MAC discretion. 
In view of the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic procedures 
other than those listed under Categories I and II should be carefully reviewed before payment. Medical 
justification may be required. You can find this rule at the Medicare Local Coverage Determination (LCD)- 
220.5, Ultrasound Diagnostic Procedures. 
 
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). 
 
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.