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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. 
 
Covered Indications 
Stress testing without cardiac imaging will be considered medically reasonable and necessary for: 
 
    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. 
    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. 
    New-onset atrial fibrillation (with no prior cardiac evaluation). 
    Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy 
(HCM). 
    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. 
         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. 
    Patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment 
elevation myocardial infarction [STEMI], a Non-ST 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. 
    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. 
    Pre-operative cardiac evaluation in patients able to exercise and who will be undergoing noncardiac surgery 
with one of the following: 
        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: 
    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 
    New-onset atrial fibrillation (with no prior cardiac evaluation). 
 
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.