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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
Myocardial Perfusion Imaging: Patients with a high pretest probability of disease are usually not candidates for 
this study unless determination of the size and reversibility of a defect are required for clinical decision 
making. Patients whose diagnosis is in question benefit most from this study. Patients with a low pretest 
probability of disease are usually not studied except when a prior exercise stress test by treadmill 
electrocardiogram (ECG) or echocardiogram (echo) is a presumed false positive. Stress MPI, preceded by 
satisfactory stress echo, is not medically necessary.  
 
Indications for Myocardial Perfusion Imaging 
1. Acute myocardial infarction (AMI) - MPI is not typically performed during the acute period of myocardial 
infarction (MI), if the diagnosis is established by other means. In selected patients, imaging is appropriate in 
the assessment of: 
 Disease severity 
 Risk assessment and/or prognosis 
 Efficacy of acute reperfusion therapy 
 Evidence of myocardial salvage 
 Suspected infarction when the combination of history and other tests is not diagnostic. 
 
2. Unstable angina - MPI may be useful as an adjunct to other tests in the diagnosis or treatment of unstable 
angina only when the combination of history and other tests is not diagnostic. In selected patients, imaging is 
appropriate for: 
 Identification of ischemia in the distribution of a known lesion or in remote areas 
 Identification of the severity/extent of disease in patients with medically unstable angina or ongoing 
ischemia 
 Measurement of left ventricular function (LVF). 3. Chronic ischemic heart disease - The use of MPI is well established in the diagnosis and management of 
CAD and is covered in these situations: 
 Diagnosis of CAD, especially in patients with atypical chest pain 
 Evaluation of abnormal or suspected false positive stress ECG 
 Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and ventricular 
arrhythmia 
 Assessment of myocardial viability after revascularization or medical management 
 Planning percutaneous transluminal coronary angioplasty (PTCA) to identify lesions causing 
ischemia, if unknown 
 Evaluation of suspected or known CAD prior to high risk surgical procedure 
 Identification of the presence, location, extent, and severity of myocardial ischemia 
 Assessment of drug therapy 
 Assessment of symptoms suggesting restenosis following PTCA 
 Assessment of symptoms suggesting ischemia following Coronary Artery Bypass Graft (CABG) 
 Follow up of symptomatic ischemic heart disease 
 
4. Congenital heart disease (CHD) - Echo is the method of choice for evaluating patients with known or 
suspected CHD. Selected patients may benefit from MPI when assessing for: 
 Diagnosis of anomalies of the coronary circulation 
 Kawasakis disease 
 
5. Post-transplant cardiac disease 
 Assessment of coronary arteriopathy 
 Evaluation for ventricular dysfunction with post-transplant rejection 
 
You can find this information in Local Coverage Determination (LCD)  Cardiac Radionuclide Imaging 
(L33457). 
 
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.