Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the EKG. We decided that the Plan does not have to pre-approve 
the nuclear stress test.  
 
You asked the Plan to pre-approve an EKG and a nuclear stress test. The Plan says that the tests are not 
medically necessary. 
 
We decided that the Plan has to pre-approve the EKG.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an EKG. Our reviewer says that an 
EKG is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has 
baseline CAD and CHF with depressed ejection fraction. He was undergoing routine follow-up cardiology 
evaluation and an EKG is a medically reasonable and necessary part of a follow-up cardiology evaluation to 
assess for any new changes in cardiac conduction or an intercurrent silent MI based on Medicare rules.  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EKG have been met. Therefore, we decided that the Plan has to pre-approve 
the EKG.  
 
We also decided that the Plan does not have to pre-approve the nuclear stress test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nuclear stress test. Our reviewer 
says that the requested nuclear stress test is not medically reasonable and necessary in this case. Our physician 
reviewer found that a regadenoson nuclear stress test would be indicated in a patient with underlying CAD and 
CHF if there were changes in symptomatology suggesting ischemia (increasing shortness of breath or chest 
discomfort) or a new documented decrease in LV function or new changes on EKG. Occasionally in someone 
who is post coronary revascularization procedure a stress test can be indicated if one has not been done in a 
number of years (PCI 2 years, CABG 5 years). This is not documented in the record. In addition, no new 
symptoms of ischemia are reported, and though the reason indicated for the nuclear test is "angina", this is 
specifically not confirmed in the medical records of the cardiology visit which reads "has been increasing 
weight, no chest pain, no SOB. Seems to be stable." Therefore, based on the record, the nuclear stress test does 
not meet criteria as medically necessary. We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the stress test have not bet met. 
Therefore, we decided that the Plan does not have to pre-approve the nuclear stress test.