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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 the following are considered not medically reasonable and necessary for cardiology non-
emergent outpatient stress testing: 
 
    Screening for coronary artery disease in asymptomatic patients unless under specific conditions as outlined 
in this LCD. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, 
Section 20 Services Not Reasonable and Necessary. 
 
    Routine screening for CAD in asymptomatic patients with diabetes mellitus.11 
 
    Routine stress testing in asymptomatic patients with abnormal prior stress imaging.6,8,10 
 
    Routine stress testing in asymptomatic patients with obstructive or nonobstructive CAD without a 
revascularization procedure.6,8,10 
 
    Exercise testing or radiologic imaging within the first 2 years following PCI without specific symptoms 
(e.g., chest pain, ECG changes, etc.).8,17,18 
 
    Utilization of SPECT MPI, PET MPI, stress echocardiography, and CMR in patients with low pretest 
probability of CAD, interpretable ECG, and the ability to exercise.6-9,49 
 
    The routine and repetitive monitoring of patients beyond the first cardiac stress test, in the absence of a 
documented change in condition (e.g., new symptoms or progression of existing symptoms). 
 
    Cardiovascular stress testing with or without cardiac imaging if the results will not affect patient 
management decisions.49 
 
    Cardiovascular stress testing with or without cardiac imaging when a decision to perform cardiac 
catheterization or other angiography has already been made.49 
     Stress testing with or without imaging for pre-operative evaluation for low risk noncardiac surgery.6-8,19,49 
 
    Stress testing with or without imaging for pre-operative evaluation of asymptomatic patients undergoing 
intermediate or high risk noncardiac surgery would not be expected for patients 12 months following a normal 
stress echocardiography, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), 
or cardiac catheterization.7,10,19 
 
    Utilization of SPECT MPI, PET MPI, stress echocardiography or CMR for the pre-operative evaluation of 
planned intermediate or high risk, noncardiac surgery, in the patient with normal or minor changes in resting 
ECG would not be expected for patients with no contraindications to exercise.6-8,17,19 
 
    Absolute contraindications to exercise stress testing (not an all-inclusive list)2,5: 
 
        Within 2 to 4 days of an acute myocardial infarction 
        High-risk unstable angina 
        Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise 
        Symptomatic severe aortic stenosis 
        Decompensated or uncontrolled congestive heart failure 
        Systolic blood pressure (BP) at rest >200 mmHG or diastolic BP at rest >110 mmHg 
        Acute pulmonary embolus or pulmonary infarction 
        Acute myocarditis or pericarditis 
        Acute aortic dissection 
        Severe pulmonary hypertension 
        Acute symptomatic medical illness 
 
    Please refer to CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCDs), Chapter 
1, Part 4, Sections 220.6.8 FDG PET for Myocardial Viability and 220.6.1 PET for Perfusion of the Heart for 
additional limitations. 
 
You can find this information in the 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.