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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 Stress testing with cardiac imaging will be considered medically reasonable and necessary for: 1. Patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms, AND any of the following: - Physical inability to perform a maximum exercise workload OR - New or previously unrecognized uninterpretable ECG OR - ECG is uninterpretable for ischemia due to any one of the following: -- Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia), -- Ventricular paced rhythm, -- Pre-excitation pattern such as Wolff-Parkinson-White, -- A greater than 1 mm ST segment depression (NOT nonspecific ST/T wave changes), -- Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria), or -- Patient on digoxin therapy. - A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or PCI; OR - Syncope and collapse (an abrupt, transient, complete loss of consciousness) for patients with an intermediate or high CHD risk (ATP III risk criteria) and where cardiac etiology is suspected based on an initial evaluation, including history, physical examination, or ECG and patient is unable to exercise; OR - Evidence or high suspicion of ventricular arrhythmias: OR - Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result; OR - Patients with recent equivocal or borderline testing where ischemia remains a concern; OR - Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study; OR - History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD); OR
- Evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-test probability for CAD regardless of ECG interpretability or ability to exercise; OR - High pre-test probability for CAD regardless of ECG interpretability or the ability to exercise, and a decision to perform cardiac catheterization or other angiography has not already been made; OR - Patients with HCM; OR 2. New-onset atrial fibrillation (with no prior cardiac evaluation). 3. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress imaging evaluation performed within the preceding 2 years and are unable to exercise. 4. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin. 5. Patients without cardiac symptoms who underwent a PCI (with stent) procedure more than 2 years prior or a CABG more than 5 years prior and have not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography [CCTA], cardiac catheterization) and are unable to exercise. 6. Patients with established CAD who experienced an ACS event (STEMI, NSTEMI, or unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time of the acute event and are currently clinically stable. 7. Evaluating new, recurrent, or worsening left ventricular dysfunction/congestive heart failure. 8. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered. 9. Pre-operative cardiac evaluation in patients not able to exercise and who will be undergoing noncardiac surgery with one of the following: - Intermediate risk for surgery (cardiac risk 1-5%), poor (less than 4 metabolic equivalents [METs]) or unknown functional capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect patient management decisions. - High risk for surgery (greater than 5% cardiac risk), poor (less than 4 METs) or unknown functional capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect patient management decisions. 10. Asymptomatic patients with a coronary calcium Agatston score greater than 400. 11. Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within the past year. 12. Patients who will be treated with interleukin 2 products for various malignant disorders.25 The Food and Drug Administration (FDA) has issued a black box warning for interleukin 2 products. See the FDA drug label for the FDA black box warning: https://labels.fda.gov/ 13. Stress echocardiography for the evaluation of moderate to severe valvular heart disease, suspected pulmonary artery hypertension, and re-evaluation of exercise-induced pulmonary hypertension to evaluate
response to therapy. 14. Stress echocardiography for the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting LVOT in patients with HCM. 15. CMR in patients with HCM when echocardiography is inconclusive or there are poor echocardiograph imaging windows. 16. Evaluation of transplant coronary artery disease (TCAD) or cardiac allograft vasculopathy (CAV) in patients with a history of organ transplantation. 17. Utilization of PET MPI in the determination of cardiac involvement using fluorodeoxyglucose (F-18 FDG) to diagnose cardiac sarcoidosis in patients who are unable to undergo MRI, have inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. Examples of patients who are unable to undergo MRI include, but are not limited to, patients with metal implants. 18. Utilization of PET MPI using fluorodeoxyglucose (F-18 FDG) to determine response to immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis. 19. Additional indications for PET Scans and SPECT are outlined in the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Sections 220.6 Positron Emission Tomography (PET) Scans, 220.6.1 PET for Perfusion of the Heart, 220.6.8 FDG PET for Myocardial Viability, and 220.12 Single Photon Emission Computed Tomography (SPECT). 20. Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests including echocardiography and nuclear cardiac imaging. However, selection of the test should be made within the context of other testing modalities so that the expected information does not become redundant. 21. Patients with recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch on an anatomic imaging study (coronary angiogram or CCTA) may have one stress test with imaging. You can find this rule in the Local Coverage Determination (LCD) for Cardiology Non-emergent Outpatient Stress Testing (L38396).
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.