Appeal type: unknown
Decision: unknown

 
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 types of stress testing with imaging addressed in this LCD include stress echocardiography, 
single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron 
emission tomography (PET) MPI, and cardiac magnetic resonance imaging (CMR). Stress testing with imaging 
can be performed with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine, 
regadenoson, or other provocative agents).
 
Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. 
However, in addition to myocardial ischemia, stress echocardiography can provide information that is not 
obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic 
obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress) and 
multiple (at rest and stress) SPECT studies. The CMR can also distinguish scar from hibernating myocardium, 
provide information about valvular function, the presence of myocardial fibrosis, the presence of 
morphological abnormalities, and provide an assessment of dynamic obstruction without radiation exposure. 
This is especially valuable in patients in whom good quality echocardiography images could not be obtained 
due to technically difficult acoustic windows. 
 
Pharmacological imaging studies may be appropriate for those patients who are unable to reach 75-100 percent 
of their age-predicted maximum heart rate by physiologic exercise. 
 
The SPECT MPI is highly accurate to diagnose flow-limiting CAD and to stratify risk of ischemic heart disease 
events.
 
A strength of SPECT is the availability of robust software programs for the interpretation of MPI. 
Hendel et al
17
 provided a multicenter assessment of the use of single-photon emission computed 
tomography myocardial perfusion imaging with appropriateness criteria. Dorbala et al has also provided 
SPECT MPI guidelines. Consistent with these guidelines, stress testing with cardiac imaging is recommended 
for patients without cardiac symptoms who underwent a PCI (with stent) procedure or a CABG more than 2 
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.
 
A stress test with cardiac imaging is also recommended for patients with cardiac 
symptoms who had a PCI procedure (with stent) or a CABG procedure more than 5 years ago and who have not undergone an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, 
CMR, CCTA, cardiac catheterization].
 
 Evidence-based guidelines also recommend stress testing with cardiac imaging for patients experiencing new, 
recurrent, or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms, and 
any of the following: a) Physical inability to perform a maximum exercise workload,
 
b) New or previously 
unrecognized uninterpretable ECG, c) ECG is uninterpretable for ischemia due to any one of the following: 1) 
Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia); 2) 
Ventricular paced rhythm; 3) Pre-excitation pattern such as Wolff-Parkinson-White; 4) A > 1 mm ST segment 
depression (Not nonspecific ST/T wave changes); 5) Left ventricular hypertrophy (LVH) with repolarization 
abnormalities, also called LVH with strain (Not without repolarization abnormalities or by voltage criteria); or 
6) Patient on digoxin therapy. Stress testing with cardiac imaging is also recommended for patients with a 
history of CAD based on a prior anatomic evaluation of the coronary arteries or a history of CABG or PCI.
 
Consistent with evidence-based guidelines, stress testing with cardiac imaging is recommended for patients 
with the following conditions: 

a) Evidence or high suspicion of ventricular arrhythmias,
 b) 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, 
c) 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, 
d) 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), 
e) 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, and 
f) 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. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35083: 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.