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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 This policy addresses the medically necessary and appropriate application of TTE, including stress echocardiography. Transesophageal echocardiography (TEE) is the subject of a separate policy statement.
A. Transthoracic Echocardiogram INDICATIONS:
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.
B. Follow-up Studies or Limited Studies INDICATIONS AND LIMITATIONS A complete study includes a full evaluation of all aspects of the heart, including the cardiac chambers, valves, blood flow, and great vessels. The images are reviewed, measured, analyzed and interpreted by the physician. A report is prepared for the patient's record. When a less than complete examination is performed for the purpose of evaluation of one specific cardiac problem, or region of the heart, the service performed is described by codes 93304, 93308 and 93321, follow-up or limited studies. When a limited service is performed, or the patient's condition requires only a limited examination, these codes must be used to indicate the appropriate service. You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) L34338, TRANSTHORACIC ECHOCARDIOGRAPHY (TTE).
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.