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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 a cardiovascular stress test (pharmacologic and non-pharmacologic) is considered medically
reasonable and necessary for the following conditions:
Stress testing without cardiac imaging is medically reasonable and necessary for:
1. Cardiac symptoms, including otherwise unexplained angina equivalent symptoms, in a patient with low pretest
probability for CAD with normal or minor changes in resting ECG and no contraindications to exercise.
2. Cardiac symptoms, including otherwise unexplained angina equivalent symptoms, in a patient with
intermediate pre-test probability for CAD with normal or minor changes in resting ECG and no
contraindications to exercise.
3. Cardiac symptoms, including otherwise unexplained angina equivalent symptoms, in a patient with diabetes
mellitus with normal or minor changes in resting ECG and no contraindications to exercise.
4. To determine functional capacity and response to therapy in patients with hypertrophic cardiomyopathy
(HCM).
5. Syncope (i.e., no prodromal symptoms, not near syncope) in patient with intermediate or high pre-test
probability of CAD.
6. Routine study > 2 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD
within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography
angiography (CCTA), cardiac catheterization].
7. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation
for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, CCTA, cardiac
catheterization].
8. Established CAD in a patient who had an acute coronary syndrome (ACS) [ST segment elevation myocardial
infarction (STEMI), Non-ST segment elevation myocardial infarction (NSTEMI), unstable angina] event
within the past 90 days provided that the patient has not undergone coronary angiography at the time of the
acute event and is currently clinically stable.
9. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm,
peripheral vascular disease, carotid artery disease, chronic renal failure) and no documented evaluation was
performed within the preceding 2 years.
10. Pre-operative cardiac evaluation in patients undergoing noncardiac surgery with15:
o Intermediate risk surgery (cardiac risk 1-5%), unknown functional capacity, and the results will affect patient
management decisions
o High risk surgery (> 5% cardiac risk), unknown functional capacity, and the results will affect patient
management decisions
Stress testing with cardiac imaging is medically reasonable and necessary for:
1. 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.
- New or previously unrecognized uninterpretable ECG.
o ECG is uninterpretable for ischemia due to any one of the following:
o Complete Left Bundle Branch Block (right bundle branch does not render ECG uninterpretable for ischemia)
o Ventricular paced rhythm
o Pre-excitation pattern such as Wolff-Parkinson-White
o > 1 mm ST segment depression (NOT nonspecific ST/T wave changes)
o LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization
abnormalities or by voltage criteria)
o 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.
- Syncope (i.e., no prodromal symptoms, not near syncope) in patient with intermediate or high pre-test probability of CAD.
- Evidence or high suspicion of ventricular arrhythmias.
- 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.
- Patients with recent equivocal or borderline testing where ischemia remains a concern.
- 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.
- 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).
- Intermediate pre-test probability for CAD regardless of ECG interpretability and ability to exercise.
- High pre-test probability for CAD regardless of ECG interpretability and ability to exercise and a decision to perform cardiac catheterization or other angiography has not already been made.
- Patient with hypertrophic cardiomyopathy.
2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin.
3. Routine study > 2 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), cardiac catheterization].
4. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, CCTA, cardiac catheterization].
5. Patients with recently demonstrated coronary stenosis of uncertain functional significance in a major
coronary branch on an anatomic imaging study (coronary angiogram or CCTA) can have one stress test with imaging.
6. Established CAD in a patient who had an acute coronary syndrome (ACS) [ST segment elevation myocardial infarction (STEMI), Non-ST segment elevation myocardial infarction (NSTEMI), unstable angina] event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is 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 undergoing noncardiac surgery with:
- Intermediate risk surgery (cardiac risk 1-5%), poor (<4 METs) or unknown functional capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect patient management decisions
- High risk surgery (> 5% cardiac risk), poor (<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 coronary calcium Agatston score >400.
11. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year.
12. Patients to be treated with interleukin 2 products for various malignant disorders.20 The 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. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) and no documented evaluation was performed within the preceding 2 years.
14. Stress echocardiography is considered reasonable and necessary 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. 15. PET MPI is considered reasonable and necessary for the determination of cardiac involvement, using Fluorodeoxyglucose (F-18 FDG), to diagnose cardiac sarcoidosis in patients who are unable to undergo magnetic resonance imaging (MRI). Examples of patients who are unable to undergo MRI include, but are not limited to, patients with metal implants. 16. Stress echocardiography is considered reasonable and necessary for the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting LVOT in patients with hypertrophic cardiomyopathy (HCM). 17. Routine study for patients with a history of organ transplantation. You can find this rule in the Local Coverage Determination (LCD): Cardiology Non-emergent Outpatient Stress Testing (L38396) effective March 15, 2020.
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.