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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 effective for services performed on or after March 14, 1995, PET scans performed at rest or 
with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and 
management of patients with known or suspected coronary artery disease using the FDA-approved 
radiopharmaceutical Rubidium 82 (Rb 82) are covered, provided the requirements below are met: 
 
1. The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a 
single photon emission computed tomography (SPECT); or 
2. The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be 
inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what 
medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an 
inconclusive test is a test(s) whose results are equivocal, technically uninterpretable, or discordant with a 
patient's other clinical data and must be documented in the beneficiary's file.) 
3. For any PET scan for which Medicare payment is claimed for dates of services prior to July 1, 2001, the 
claimant must submit additional specified information on the claim form (including proper codes and/or 
modifiers), to indicate the results of the PET scan. The claimant must also include information on whether the 
PET scan was performed after an inconclusive noninvasive cardiac test. The information submitted with 
respect to the previous noninvasive cardiac test must specify the type of test performed prior to the PET scan 
and whether it was inconclusive or unsatisfactory. These explanations are in the form of special G codes used 
for billing PET scans using Rb 82. Beginning July 1, 2001, claims should be submitted with the appropriate 
codes. 
 
You can find this rule in the National Coverage Determination (NCD) - PET for Perfusion of the Heart 
(220.6.1) - Effective April 3, 2009. 
 
The rules say that effective for services performed on or after October 1, 2003, PET scans performed at rest or 
with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and 
management of patients with known or suspected coronary artery disease using the FDA-approved 
radiopharmaceutical ammonia N-13 are covered, provided the requirements below are met: 
 
1. The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a 
SPECT; or 
2. The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be 
inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an 
inconclusive test is a test whose results are equivocal, technically uninterpretable, or discordant with a patient's 
other clinical data and must be documented in the beneficiary's file.) 
 
You can find this rule in the National Coverage Determination (NCD) - PET for Perfusion of the Heart 
(220.6.1) - Effective April 3, 2009. 
 
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.