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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 noninvasive testing in the outpatient setting to assess for coronary artery disease (CAD) and 
left ventricular (LV) dysfunction may be accomplished by utilizing conventional exercise stress testing without 
imaging or by utilizing exercise or pharmacologic stress testing with imaging. 
 
Cardiovascular stress testing, also referred to as exercise stress test (EST), exercise electrocardiogram, exercise 
treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information 
about how the heart responds to exertion. 
 
Types of stress testing with imaging addressed in this LCD include stress echocardiography, single photon 
emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron emission tomography 
(PET) MPI, and cardiac magnetic resonance imaging (CMR). Stress testing with imaging can be performed 
with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine, regadenoson, or other 
provocative agents). 
 
Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. 
However, in addition to myocardial ischemia, stress echocardiography can provide information that is not 
obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic 
obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress) and 
multiple (at rest and stress) SPECT studies. The CMR can also distinguish scar from hibernating myocardium, 
provide information about valvular function, the presence of myocardial fibrosis, the presence of 
morphological abnormalities, and provide an assessment of dynamic obstruction without radiation exposure. 
This is especially valuable in patients in whom good quality echocardiography images could not be obtained 
due to technically difficult acoustic windows. In many instances, EST may be combined with imaging 
procedures, such as MPI, echocardiography, or other imaging procedures. 
 
A pharmacologic stress test may be performed when patients are unable to exercise. This test involves the 
administration of a medication that is designed to make the heart respond as if the patient was exercising. The 
pharmacologic testing allows the provider to determine how the heart responds to stress in the absence of 
exercise. 
 
Imaging of myocardial perfusion can also be combined with myocardial metabolism imaging with 
fluorodeoxyglucose (F-18 FDG) for the assessment of myocardial viability in areas of resting hypoperfusion 
and dysfunctional myocardium. The stress protocols are, for the most part, similar for all cardiac PET perfusion 
agents. The specific differences in acquisition protocols for rubidium (Rb-82) and ammonia N-13 are related to 
the duration of uptake and clearance of these radiopharmaceuticals and their physical half-lives. 
 
You can find these rules 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.