Appeal type: unknown
Decision: unknown

 
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 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 electrocardiogram (ECG or EKG); or 
- EKG is uninterpretable for ischemia due to certain causes. 
2. New-onset atrial fibrillation (with no prior cardiac evaluation). 
3. Patients with disease conditions associated with coronary artery disease (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 percutaneous coronary intervention (PCI) (with 
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 and are unable to exercise. 
6. Patients with established CAD who experienced an acute coronary syndrome (ACS) event 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 intermediate risk 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. 13. Stress echocardiography for the evaluation of moderate to severe valvular heart disease, suspected 
pulmonary artery hypertension, and re-evaluation of exercise-induced pulmonary hypertension to 
evaluate response to therapy. 
14. Stress echocardiography for the detection and quantification of dynamic left ventricular outflow tract 
(LVOT) obstruction in the absence of resting LVOT in patients with HCM. 
15. Cardiac magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM) when 
echocardiography is inconclusive or there are poor echocardiograph imaging windows. 
16. Evaluation of transplant coronary artery disease (TCAD) or cardiac allograft vasculopathy (CAV) in 
patients with a history of organ transplantation. 
17. Utilization of positron emission tomography (PET) myocardial perfusion imaging (MPI) in the 
determination of cardiac involvement using fluorodeoxyglucose (F-18 FDG) to diagnose cardiac 
sarcoidosis in patients who are unable to undergo magnetic resonance imaging (MRI), have 
inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. 
Examples of patients who are unable to undergo MRI include, but are not limited to, patients with metal 
implants. 
18. Utilization of PET MPI using fluorodeoxyglucose (F-18 FDG) to determine response to 
immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis. 
19. Additional indications for PET Scans and single-photon emission computed tomography (SPECT) are 
outlined in the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) 
Manual, Chapter 1, Part 4, Sections 220.6 Positron Emission Tomography (PET) Scans, 220.6.1 PET 
for Perfusion of the Heart, 220.6.8 FDG PET for Myocardial Viability, and 220.12 Single Photon 
Emission Computed Tomography (SPECT). 
20. Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests 
including echocardiography and nuclear cardiac imaging. However, selection of the test should be made 
within the context of other testing modalities so that the expected information does not become 
redundant. 
21. Patients with recently demonstrated coronary stenosis of uncertain functional significance in a major 
coronary branch on an anatomic imaging study may have one stress test with imaging. 
 
You can find these rules in 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.