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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that stress testing with cardiac imaging will be considered medically reasonable and necessary 
for: 
1. 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 ECG
 
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 more than 1 milimeter (mm) ST segment depression  -Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH 
 with strain (NOT without repolarization abnormalities or by voltage criteria), or 
-Patient on digoxin therapy. 
-A history of Coronary Artery Disease (CAD) based on a prior anatomic evaluation of the 
 coronary arteries OR a history of Coronary artery bypass graft (CABG) or Percutaneous  
 Coronary Intervention (PCI); OR 
-Syncope and collapse (an abrupt, transient, complete loss of consciousness) for patients with an 
 intermediate or high Congenital Heart Disease (CHD) risk 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 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 Hypertrophic Cardiomyopathy (HCM);
 
OR 
2. New-onset atrial fibrillation (with no prior cardiac evaluation). 
3. Patients with disease conditions associated with CAD with no stress imaging evaluation performed 
within the preceding 2 years and are unable to exercise. 4. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin. 
5. 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 and are unable to exercise. 
6. Patients with established CAD who experienced an Acute Coronary Syndrome (ACS) event 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. 
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. 
9. 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 (less than 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 (more than 5% cardiac risk), poor (less than 4 METs) or unknown functional  
capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will  
affect patient management decisions. 
10. Asymptomatic patients with a coronary calcium Agatston score greater than 400. 
11. Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within 
the past year. 
12. Patients who will be treated with interleukin 2 products for various malignant disorders. The Food and 
Drug Administration (FDA) has issued a black box warning for interleukin 2 products.  
13. 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. 
14. Stress echocardiography for the detection and quantification of dynamic left ventricular outflow tract 
(LVOT) obstruction in the absence of resting LVOT in patients with HCM. 
15. Cardiovascular Magnetic Resonance Imaging (CMR) in patients with HCM when echocardiography is 
inconclusive or there are poor echocardiograph imaging windows. 
16. Evaluation of transplant coronary artery disease (TCAD) or cardiac allograft vasculopathy (CAV) in 
patients with a history of organ transplantation. 
17. Utilization of positive emission tomography (PET) Myocardial Perfusion Imaging (MPI) in 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), have 
inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. 
Examples of patients who are unable to undergo MRI include, but are not limited to, patients with metal 
implants. 
18. Utilization of PET MPI using fluorodeoxyglucose (F-18 FDG) to determine response to 
immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis. 
19. Additional indications for PET Scans and SPECT are outlined in the CMS IOM Publication 100-
03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Sections 220.6 
Positron Emission Tomography (PET) Scans, 220.6.1 PET for Perfusion of the Heart, 220.6.8 FDG 
PET for Myocardial Viability, and 220.12 Single Photon Emission Computed Tomography (SPECT). 
20. Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests 
including echocardiography and nuclear cardiac imaging. However, selection of the test should be made 
within the context of other testing modalities so that the expected information does not become 
redundant. 
21. Patients with recently demonstrated coronary stenosis of uncertain functional significance in a major 
coronary branch on an anatomic imaging study (coronary angiogram or CCTA) may have one stress test 
with imaging. 

You can find this information in the Local Coverage Determination (LCD): Cardiology Non-emergent 
Outpatient Stress Testing (L35083). 
 
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.