Appeal type: unknown
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 say that ultrasound diagnostic procedures utilizing low energy sound waves are being widely 
employed to determine the composition and contours of nearly all body tissues except bone and air-filled 
spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of 
the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in 
diagnosing a wide variety of conditions. 
 
Ultrasound diagnostic procedures are listed below and are divided into two categories. Medicare coverage is 
extended to the procedures listed in Category I. Periodic claims review by the A/Medicare Administrative 
Contractor (A/MAC) medical consultants should be conducted to ensure that the techniques are medically 
appropriate, and the general indications specified in these categories are met. Techniques in Category II are 
considered experimental and should not be covered at this time. 
 
Indications and Limitations of Coverage 
 
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. 
 
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 these rules in the National Coverage Determination (NCD) Ultrasound Diagnostic Procedures 
220.5. 
 
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.