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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 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 following19: 
        Intermediate risk for surgery (cardiac risk 1-5%), unknown functional capacity, and the results will affect 
patient management decisions. 
        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 greater than 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 (Less than 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 (Greater than 5% cardiac risk), poor (Less than 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 greater than 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. See the FDA drug label 
for the FDA black box warning: https://labels.fda.gov/  
 You can find this information in Medicare's 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.