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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 indications and limitations of coverage of cardiac PET scans: 
1. Rubidium 82 (Effective March 14, 1995) 
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:  
 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 
 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.) 
 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. 
2. Ammonia N-13 (Effective October 1, 2003) 
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:  The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, 
a SPECT; or 
 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations (NCD) Manual Chapter 1, Section 220.6.1. 
 
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.