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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 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; Assessment of congenital 
anomalies of coronary arteries; 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; 
 
The "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac 
Surgery" (JACC 2007; 50:e159-e242) provides this information: 
 
High risk surgery: aortic and peripheral vascular surgery 
 
Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck 
surgery, orthopedic surgery, prostate surgery. 
 
Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory 
surgery 
 Poor functional capacity = less than 4 METS 
 
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 
 
Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional 
capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the 
management. Evaluation of ventricular function in patients with non-ischemic myocardial disease; Evaluation 
of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether 
to implant a defibrillator or biventricular pacemaker; Evaluation of a patient receiving chemotherapeutic drugs 
which are potentially cardiotoxic (e.g., adriamycin). First pass studies will be considered medically necessary 
only when information sought is immediately relevant to the management of the patients clinical condition and 
has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or 
equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification 
of shunts. Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive 
diagnosis of myocardial infarction by EKG or enzyme testing. 
 
Patient selection should be based on clinical grounds: Patients with a high pretest probability of disease are not 
usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its 
functional consequences may be required for clinical decision-making. Patients with a moderate probability of 
disease benefit the most from the study when the diagnosis is in question. Selection of tests should be made 
within the context of other tests, scheduled and previously performed, so that the anticipated information 
obtained is unique and not redundant. 
 
Limitations: 
 
Special Equipment Requirements: Given the limitations of uptake, low photon energy and redistribution, the 
cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. 
However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be 
made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who 
bill this service must certify within their records that their laboratories are specially equipped to process such 
studies. All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-
physician provider. All stress tests must be performed under the direct supervision of a physician. The nuclear 
test components must be performed under the general supervision of a physician. 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 this information in Medicare's 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.