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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 on-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 percent 
are normally followed on an annual basis, whereas patients with a diameter reduction of greater than 50 percent 
are normally followed every six months. It is not necessary to monitor patients with a diameter reduction of 
less than 30 percent. 
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 percent 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. 
Non-invasive vascular studies are medically necessary only if the outcome will potentially impact the clinical 
management of the patient. Services are deemed medically necessary when all of the following conditions are 
met: 
 
1) Significant signs/symptoms of ischemia are present; 
 
2) The information is necessary for appropriate medical and/or surgical management; and 
 
3) The test is not redundant of other diagnostic procedures that must be performed. 
 
Limitations 
 
Dizziness is not a typical indication unless associated with other localizing signs or symptoms. However, 
episodic dizziness with symptom characteristics typical of transient ischemic attacks may indicate medical 
necessity, especially when other more common sources (for example, postural hypotension, arrhythmia or 
transiently decreased cardiac output as demonstrated by cardiac events monitoring) have been previously 
excluded.  
When reporting syncope as an indication for this service, it is necessary to document that other, more common 
causes have been ruled out. 
When an uninterpretable study results in performing another type of study, only the successful study should be 
billed. 
Non-invasive studies are reasonable and necessary only if the outcome will potentially impact the clinical 
course of the patient. For example, the studies are unnecessary when the patient is (or is not) proceeding on to 
other diagnostic and/or therapeutic procedures regardless of the outcome of the non-invasive studies. If it is 
obvious from the findings of the history and physical examination that the patient is going to proceed to 
angiography, then non-invasive vascular studies are not medically necessary.  
Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins 
during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would 
not generally be expected (American College of Radiology, 2010). Consequently, documentation must clearly 
support the medical necessity if both procedures are performed during the same encounter, and be available 
upon request. 
When reporting syncope as an indication for this service, it is necessary to document that other, more common 
causes have been ruled out. 
 
Generally, it is not expected that these services would be performed more than once in a year, excluding 
inpatient hospital and emergency room places of service. You can find this information in the Local Coverage 
Determination (LCD) for Non-invasive Extracranial Arterial Studies (L33695). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.