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The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules state that Cardiovascular nuclear imaging is indicated for the following:Assessment of the functional and prognostic importance of angina;Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy;Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years;Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction;Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned;Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures;Quantification and surveillance of myocardial infarction and prognostication in patients with infarction;Assessment of congenital anomalies of coronary arteries;Preoperativeassessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in:-patients with minor or intermediate clinical risk predictors and poor functional capacity;-patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity undergoing high risk non-cardiac surgery; The "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery" (JACC 2007; 50:e159-e242) provides this information:High risk surgery: aortic and peripheral vascular surgeryIntermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery.Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgeryPoor functional capacity = less than 4 METSClinical risk factors:1) history of ischemic heart disease2) history of compensated or prior heart failure3) history of cerebrovascular disease4) diabetes mellitus5) renal insufficiency
Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood thatthe results of the cardiac testing would change the management. Evaluation of ventricular function in patients with non-ischemic myocardial disease;Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker;Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin).First pass studies will be considered medically necessary only when information sought is immediately relevant to the management of the patient's clinical condition, and has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts,Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by EKG or enzyme testing.Patient selection should be based on clinical grounds:Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making.Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question.Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant.You can find this information and a full list of indications and limitations in Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L33960).