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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 a stress echocardiography may be necessary when the evaluation could contribute significant 
information to the patient's condition or treatment plan. A non-imaging stress test focuses on the hemodynamic 
and electrocardiographic responses to stress. To enhance the diagnostic specificity, the stress test may be 
combined with echocardiographic imaging or scintigraphic imaging. A contrast agent may be used with 
echocardiographic imaging to enhance endocardial visualization and diagnostic accuracy. When two (or more) 
imaging studies (e.g., ultrasound and scintigraphy) are billed without a supporting clinical indication for each, 
one of the services will be denied as not medically necessary. 
 
Stress echocardiography may be indicated in the care of patients with real or suspected ischemic heart disease 
in the following clinical settings: 
1. To detect coronary artery disease in patients presenting with chest pains including atypical chest pains 
and exertional dyspnea when the suspicion of CAD is high. 
2. To assess prognosis and functional capacity in patients following an acute myocardial infarction. 
3. To evaluate the extent of exercise induced ischemia in patients who have had a revascularization 
procedure (PCTA, stent or coronary bypass) or patients who have known CAD disease. 
4. In women, stress imaging has been recommended as the "initial test." 
5. To evaluate a prior nondiagnostic or abnormal ECG exercise test as a substitute for a nuclear perfusion 
study. 
6. To evaluate patients who are at high risk for myocardial infarction prior to a scheduled major surgical 
procedure (e.g., aneurysm, vascular surgery, surgeries with large volume shifts, etc) or transplant 
procedure. 
7. To evaluate patients presenting with various arrhythmias (atrial and/or ventricular) or syncope (near or 
pre), when the suspicion of occult coronary artery disease is high. 
8. To evaluate patients when an indicated standard exercise ECG is likely to be non-diagnostic, including 
patients with an abnormal resting ECG, orthostatic or hyperventilation induced ECG changes, 
nonspecific ST-T abnormalities due to ventricular hypertrophy drugs or associated intraventricular 
conduction defect. 9. To assess myocardial viability (hibernating myocardium) for planned revascularization or functional 
significance of coronary lesions (if not already known) in planning percutaneous transluminal coronary 
angioplasty. 
10. To evaluate cardiomyopathy when the evaluation could reasonably be expected to contribute significant 
information regarding the patient's condition or treatment plan. 
11. To evaluate ventricular dysfunction due to post-transplant rejection when the evaluation could 
reasonably be expected to contribute significant information regarding the patient's condition or 
treatment plan. 
12. To evaluate congenital heart disease, when stress echocardiography helps to determine systemic and 
right ventricular function at rest and following stress and the presence of any other structural 
abnormalities, including valvular lesions that may be accentuated with stress. 
13. Additionally, the test may be combined with Doppler intervention to evaluate exercise hemodynamics 
in patients with mitral stenosis, mitral regurgitation, pulmonary hypertension, aortic 
stenosis/regurgitation, prosthetic valves and other conditions where symptoms suggest a more severe 
impairment than the assessment done at rest. 
14. Dobutamine stress echo may be indicated to detect low gradient, low output (aortic stenosis) or 
clinically silent transplant coronary disease. 
You can fine this information in the Local Coverage Determination LCD: L33577. 
 
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.