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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 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. 
            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 
                > 1 mm ST segment depression (NOT nonspecific ST/T wave changes) 
                LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization 
abnormalities or by voltage criteria) 
                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.4,5,6,7,11 
    9. Pre-operative cardiac evaluation in patients undergoing noncardiac surgery with4,5,6,11,13,15: 
        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  
    3. Asymptomatic patients with coronary calcium Agatston score >400.4,5,6,13 
    4. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past 
year.8,19 
   5. 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/ 
    6. 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.13 
    7. 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.4,21 
    8. 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.7,11,22,23 
   9. 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).10 
   10. Routine study for patients with a history of organ transplantation. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Cardiology Non-emergent 
Outpatient Stress Testing (L38396). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.