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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 non-invasive extracranial arterial studies will be considered medically reasonable and 
necessary under the following circumstances: 
 To initially evaluate a patient presenting with an asymptomatic carotid bruit identified on physical 
examination. However, repeatedly using this test for a patient with an asymptomatic carotid bruit with 
no evidence of carotid stenosis is routine monitoring. As such, it is considered screening and is 
noncovered. 
 To evaluate a symptomatic patient with a carotid bruit(s). 
 To monitor a patient with known carotid stenosis. Patients demonstrating a diameter reduction of 30-
50% are normally followed on an annual basis, whereas patients with a diameter reduction of greater 
than 50% are normally followed every six months. It is not necessary to monitor patients with a 
diameter reduction of less than 30%. 
 To initially evaluate a patient who has had a recent stroke (recent is defined as less than six months) to 
determine the cause of the stroke. 
 To evaluate a patient with focal cerebral or ocular transient ischemic symptoms (including, but not 
limited to, localizing symptoms, weakness of one side of the face, slurred speech, weakness of limb, 
ocular microembolism, arterial occlusions on retinal examination (branch or central), ischemic optic 
neuropathy, suspected dural or carotid cavernous fistulae). Ocular transient ischemic attacks are defined 
as retinal or visual field deficits and not temporarily blurred vision. 
 To evaluate a patient with syncope that is strongly suggestive of vertebrobasilar or bilateral carotid 
artery disease in etiology, as suggested by medical history. 
 To evaluate a patient with retinal arterial emboli (Hollenhorst plaques) 
 To evaluate a patient with transient monocular blindness (amaurosis fugax). 
 To evaluate a patient with signs/symptoms of subclavian steal syndrome. The symptoms usually 
associated with subclavian steal syndrome are a bruit in the supraclavicular fossa, unequal radial pulses, 
arm claudication following minimal exercise, and a difference of 20mmHg or more between the systolic 
blood pressures in the arms. 
 To evaluate a patient with proven carotid disease on medical management in whom cerebrovascular 
symptoms become recurrent.  To evaluate a patient presenting with an injury to the carotid artery or blunt neck trauma. 
 To evaluate a patient with vasculitis involving the extracranial carotid arteries. 
 To evaluate a patient with a suspected aneurysm of the carotid artery. This is suspected in patients with 
swelling of the neck particularly if occurring post carotid endarterectomy. 
 To evaluate a patient with suspected dissection. 
 To evaluate pulsatile neck masses. 
 To monitor patients who are post carotid endarterectomy. These patients are normally followed with 
duplex ultrasonography on the affected side at 6 weeks, 6 months, 1 year, and annually thereafter.  
 To preoperatively validate the degree of carotid stenosis of a patient whose previous duplex scan 
revealed a greater than 70% diameter reduction. The duplex is only covered when the surgeon questions 
the validity of the previous study and the repeat test is being performed in lieu of a carotid arteriogram. 
 Preoperative evaluation of patients scheduled for major cardiovascular surgical procedures when there 
is evidence of systemic atherosclerosis. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33695: Non-invasive 
Extracranial Arterial Studies. 
 
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.