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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 workload2,5,6,8-10,15,20; OR 
 
New or previously unrecognized uninterpretable ECG2,5,6,8-10 OR; 
ECG is uninterpretable for ischemia due to any one of the following2,5,8,9,15,21: 
 
Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia),21 
 
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 
 
Patient 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;6,8,10,15,16 OR 
 
Evidence or high suspicion of ventricular arrhythmias:6,7,8,10 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;20,22 OR 
 
Patients with recent equivocal or borderline testing where ischemia remains a concern;8,15,20 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;2,5 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);8,22 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;7,8 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;7,8,10,15 OR 
 
Patients with HCM;14 OR 
 
New-onset atrial fibrillation (with no prior cardiac evaluation).10,12,13 
 
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.5,7,10,17 
 
Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin.6,8 
 
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.6,7,8,15,17,18 
 
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.6,8 
 
Evaluating new, recurrent, or worsening left ventricular dysfunction/congestive heart failure.6-8,10,23 
 
The following are considered not medically reasonable and necessary: 
 
Screening for coronary artery disease in asymptomatic patients unless under specific conditions as outlined in 
this LCD. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 
20 Services Not Reasonable and Necessary. 
 
Routine screening for CAD in asymptomatic patients with diabetes mellitus.11 
 Routine stress testing in asymptomatic patients with abnormal prior stress imaging.6,8,10 
 
Routine stress testing in asymptomatic patients with obstructive or nonobstructive CAD without a 
revascularization procedure.6,8,10 
 
You can find this information in the Local Coverage Determination (LCD) Cardiology Non-emergent 
Outpatient Stress Testing L38396. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.