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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 the following are considered not medically reasonable and necessary: 
1. 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. 
2. Routine screening for CAD in asymptomatic patients with diabetes mellitus. 
3. Routine stress testing in asymptomatic patients with abnormal prior stress imaging. 
4. Routine stress testing in asymptomatic patients with obstructive or nonobstructive CAD without a 
revascularization procedure. 
5. Exercise testing or radiologic imaging within the first 2 years following PCI without specific symptoms 
(e.g., chest pain, ECG changes, etc.). 
6. Utilization of SPECT MPI, PET MPI, stress echocardiography, and CMR in patients with low pretest 
probability of CAD, interpretable ECG, and the ability to exercise. 
7. The routine and repetitive monitoring of patients beyond the first cardiac stress test, in the absence of a 
documented change in condition (e.g., new symptoms or progression of existing symptoms). 
8. Cardiovascular stress testing with or without cardiac imaging if the results will not affect patient 
management decisions. 
9. Cardiovascular stress testing with or without cardiac imaging when a decision to perform cardiac 
catheterization or other angiography has already been made. 
10. Stress testing with or without imaging for pre-operative evaluation for low risk noncardiac surgery. 11. Stress testing with or without imaging for pre-operative evaluation of asymptomatic patients 
undergoing intermediate or high risk noncardiac surgery would not be expected for patients 12 months 
following a normal stress echocardiography, SPECT MPI, PET MPI, CMR, coronary computed 
tomography angiography (CCTA), or cardiac catheterization. 
12. Utilization of SPECT MPI, PET MPI, stress echocardiography or CMR for the pre-operative evaluation 
of planned intermediate or high risk, noncardiac surgery, in the patient with normal or minor changes in 
resting ECG would not be expected for patients with no contraindications to exercise. 
13. Absolute contraindications to exercise stress testing
 
(not an all-inclusive list): 
o Within 2 to 4 days of an acute myocardial infarction 
o High-risk unstable angina 
o Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise 
o Symptomatic severe aortic stenosis 
o Decompensated or uncontrolled congestive heart failure 
o Systolic blood pressure (BP) at rest >200 mmHG or diastolic BP at rest >110 mmHg 
o Acute pulmonary embolus or pulmonary infarction 
o Acute myocarditis or pericarditis 
o Acute aortic dissection 
o Severe pulmonary hypertension 
o Acute symptomatic medical illness 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38396: Cardiology Non-
emergent Outpatient Stress Testing. 
 
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.