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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 cardiovascular nuclear imaging employs non-invasive techniques to assess alterations in 
coronary artery flow, and ventricular function. 
 
The specific imaging technique (perfusion versus ventricular function) and the reason for the imaging 
determine which radionuclide agent is employed. A myocardial perfusion study utilizes an imaging isotope 
agent that reflects segmental and global myocardial blood flow and uptake, the interpretation of which is used 
to make inference about the presence of scar and ischemia. These tests may be performed at rest and during 
exercise, or with pharmacologic intervention when exercise cannot be performed. The acquisition of the images 
may be planar (single plane) or by multiple planes with computer integration, SPECT (single-photon emission 
computer tomography). 
 
Cardiovascular nuclear imaging is indicated for the following: 
 
Assessment of the functional and prognostic importance of angina; 
 
Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by 
drugs, bundle branch block, or left ventricular hypertrophy; 
 
Assessment of congenital anomalies of coronary arteries; 
 
Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with 
known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a 
revascularization procedure within the past two years; 
 
Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed 
heart failure or left ventricular systolic dysfunction; 
 
Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary 
angiography are not planned; 
 
Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-
perfusion procedures; 
 Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; 
 
Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative 
management in: 
 
    patients with minor or intermediate clinical risk predictors and poor functional capacity; 
    patients with intermediate or high likelihood of coronary heart disease, or 
    patients with poor functional capacity undergoing high risk non-cardiac surgery; 
 
Clinical risk factors: 
 
            1) history of ischemic heart disease 
            2) history of compensated or prior heart failure 
            3) history of cerebrovascular disease 
            4) diabetes mellitus 
            5) renal insufficiency 
 
Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac 
symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., 
electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by 
Medicare.  
 
Tests that are anticipated to provide information duplicative of another test already performed will be denied as 
not medically necessary. 
 
Tests performed when the results would not be anticipated to influence medical management decisions will be 
denied as not medically necessary. 
 
Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan will denied as not 
medically necessary. 
 
Infarct avid scintigraphy will be denied if the diagnosis of myocardial infarction has already been confirmed by 
enzymes and/or EKG. 
 
Tests performed unrelated to changes in a patient's signs or symptoms, or for immediate pre-operative 
evaluation will be denied as medically unnecessary. 
 
Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one 
year following normal catheterization or non-invasive test will be considered medically unnecessary and 
denied. 
 
Tests performed for preoperative evaluation in patients undergoing low-risk surgery will be denied. 
You can find these rules in the Local Coverage Determination (LCD) Cardiovascular Nuclear Medicine 
L33560. 
 
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.