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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 without cardiac imaging will be considered medically reasonable and necessary 
for: 
1. Patients with low or intermediate pre-test probability for CAD who are exhibiting cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting 
ECG and no contraindications to exercise.
5-10
 
2. Patients with diabetes mellitus who are exhibiting cardiac symptoms, including otherwise unexplained 
angina equivalent symptoms, with normal or minor changes in resting ECG and no contraindications to 
exercise.
11
 
3. New-onset atrial fibrillation (with no prior cardiac evaluation).
10,12,13
 
4. Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy 
(HCM).
14
 
5. Patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope 
(an abrupt, transient, complete loss of consciousness) and cardiac etiology is suspected based on an 
initial evaluation, including history, physical examination, or ECG and the patient is able to 
exercise.
6,8,10,15,16
 
6. Patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a 
stent) procedure more than 2 years prior or a coronary artery bypass graft (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 able to exercise.
6,7,8,15,17,18
 
7. Patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment 
elevation myocardial infarction [STEMI], a NonST segment elevation myocardial infarction 
[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 and able to exercise.
6,8
 
8. 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 testing 
evaluation performed within the preceding 2 years and who are able to exercise.
5,7,10,17
 
9. Pre-operative cardiac evaluation in patients able to exercise and who will be undergoing noncardiac 
surgery with one of the following
19
: 
 
o Intermediate risk for surgery (cardiac risk 1-5%), unknown functional capacity, and the results 
will affect patient management decisions. o High risk for surgery (> 5% cardiac risk), unknown functional capacity, and the results will 
affect patient management decisions. 
You can find this rule at Local Coverage Determination (LCD) L35083: Cardiology Non-emergent Outpatient 
Stress Testing (eff. 4/25/21). 
 
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.