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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: 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 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 > 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 patients on digoxin therapy. 
 
A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or 
PCI;6,8,15 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 New-onset atrial fibrillation (with no prior cardiac evaluation). 
 
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. 
 
Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin. 
 
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. 
 
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. 
 
Evaluating new, recurrent, or worsening left ventricular dysfunction/congestive heart failure. 
 
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. 
 
 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 (<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 (> 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. 
 
Asymptomatic patients with a coronary calcium Agatston score >400. 
 
Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within the past 
year. 
 
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/  
 
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. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD)- L35083, Cardiology Non-
emergent Outpatient Stress Testing. 
 
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.