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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: 
1. 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 workload
2,5,6,8-10,15,20
; OR 
 New or previously unrecognized uninterpretable ECG
2,5,6,8-10 
OR; 
o ECG is uninterpretable for ischemia due to any one of the following
2,5,8,9,15,21
: 
 
 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. 
 
o 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 
o 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 
o Evidence or high suspicion of ventricular arrhythmias:
6,7,8,10 
OR 
o 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 
o Patients with recent equivocal or borderline testing where ischemia remains a concern;
8,15,20 
OR 
o 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 
o 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 o 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 
o 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 
o Patients with HCM 
 
You can find this information in Local Coverage Determination (LCD): Cardiology Non-emergent Outpatient 
Stress Testing (L35083). 
 
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.