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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 without cardiac imaging will be considered medically reasonable and 
necessary for: 
1. Patients with low or intermediate pre-test probability for CAD who are exhibiting cardiac symptoms, 
including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting 
ECG and no contraindications to exercise. 
2. Patients with diabetes mellitus who are exhibiting cardiac symptoms, including otherwise unexplained 
angina equivalent symptoms, with normal or minor changes in resting ECG and no contraindications to 
exercise. 
3. New-onset atrial fibrillation (with no prior cardiac evaluation). 
4. Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy 
(HCM). 
5. Patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope 
(an abrupt, transient, complete loss of consciousness) and cardiac etiology is suspected based on an 
initial evaluation, including history, physical examination, or ECG and the patient is able to exercise. 
6. Patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a 
stent) procedure more than 2 years prior or a coronary artery bypass graft (CABG) more than 5 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 able to exercise. 
7. Patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment 
elevation myocardial infarction [STEMI], a NonST segment elevation myocardial infarction 
[NSTEMI], or unstable angina) within the past 90 days provided that they did not undergo coronary 
angiography at the time of the acute event and are currently clinically stable and able to exercise. 
8. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, 
peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress testing 
evaluation performed within the preceding 2 years and who are able to exercise. 
9. Pre-operative cardiac evaluation in patients able to exercise and who will be undergoing noncardiac 
surgery with one of the following: 
o Intermediate risk for surgery (cardiac risk 1-5%), unknown functional capacity, and the results 
will affect patient management decisions. 
o High risk for surgery (> 5% cardiac risk), unknown functional capacity, and the results will 
affect patient management decisions.  
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; OR 
 New or previously unrecognized uninterpretable ECG
 
OR; 
 ECG is uninterpretable for ischemia due to any one of the following: 
 
 
 Complete left bundle branch block (right bundle branch does not render 
ECG uninterpretable for ischemia), 
 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. 
 A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a 
history of CABG or PCI;
 
OR 
 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;
 
OR 
 Evidence or high suspicion of ventricular arrhythmias:
 
OR 
 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;
 
OR 
 Patients with recent equivocal or borderline testing where ischemia remains a 
concern;
 
OR 
 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;
 
OR 
 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);
 
OR  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;
 
OR 
 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;
 
OR 
 Patients with HCM;
 
OR 
2. New-onset atrial fibrillation (with no prior cardiac evaluation). 
3. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, 
peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress imaging 
evaluation performed within the preceding 2 years and are unable to exercise. 
4. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin. 
5. Patients without cardiac symptoms who underwent a PCI (with stent) procedure more than 2 years prior 
or a CABG more than 5 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. 
6. Patients with established CAD who experienced an ACS event (STEMI, NSTEMI, or unstable angina) 
within the past 90 days provided that they did not undergo coronary angiography at the time of the 
acute event and are currently clinically stable. 
7. Evaluating new, recurrent, or worsening left ventricular dysfunction/congestive heart failure. 
8. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected 
hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be 
considered. 
9. Pre-operative cardiac evaluation in patients not able to exercise and who will be undergoing noncardiac 
surgery with one of the following 
 Intermediate risk for surgery (cardiac risk 1-5%), poor (<4 metabolic equivalents [METs]) or 
unknown functional capacity, inability to exercise adequately or ECG uninterpretable for 
ischemia, and the results will affect patient management decisions. 
 High risk for surgery (> 5% cardiac risk), poor (<4 METs) or unknown functional capacity, 
inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect 
patient management decisions. 
10. Asymptomatic patients with a coronary calcium Agatston score >400. 
11. Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within 
the past year. 
12. Patients who will be treated with interleukin 2 products for various malignant disorders. The Food and 
Drug Administration (FDA) has issued a black box warning for interleukin 2 products.  
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.