Exercise testing is done to evaluate functional capacity and to assess the
severity and type of impairment of existing, as well as undiagnosed
conditions. The pulmonary stress test will be considered medically necessary
for these conditions:  
  
 **INDICATIONS:**  
  
 **Evaluation of exercise tolerance**  
  
 Determination of functional impairment or capacity  
 Determination of exercise-limiting factors and pathophysiologic mechanisms  
  
 **Evaluation of undiagnosed exercise intolerance**  
  
 Assessing contribution of cardiac and pulmonary etiology in coexisting
disease  
 Symptoms disproportionate to resting pulmonary and cardiac tests  
 Unexplained dyspnea when initial cardiopulmonary testing is nondiagnostic  
  
 **Evaluation of patients with cardiovascular disease**  
  
 Functional evaluation and prognosis in patients with heart failure  
 Selection for cardiac transplantation  
 Exercise prescription and monitoring response to exercise training for
cardiac rehabilitation (special circumstances; i.e., pacemakers)  
  
 **Evaluation of patients with respiratory disease**  
  
 Functional impairment assessment (see specific clinical applications)  
 Chronic obstructive pulmonary disease:  
     \- Establishing exercise limitation(s) and assessing other potential contributing factors, especially occult heart disease (ischemia)  
     \- Determination of magnitude of hypoxemia and for O2 prescription  
     \- When objective determination of therapeutic intervention is necessary and not adequately addressed by standard pulmonary function testing  
 Interstitial lung diseases:  
     \- Detection of early (occult) gas exchange abnormalities  
     \- Overall assessment/monitoring of pulmonary gas exchange  
     \- Determination of magnitude of hypoxemia and for O2 prescription  
     \- Determination of potential exercise-limiting factors  
     \- Documentation of therapeutic response to potentially toxic therapy  
 Pulmonary vascular disease (careful risk-benefit analysis required)  
 Cystic fibrosis  
 Exercise-induced bronchospasm  
  
 ** _Specific clinical applications include:_**  
  
1) Preoperative evaluation for:  
  
 Surgery involving lung resection  
 Elderly patients undergoing major abdominal surgery  
 Lung volume reduction surgery for emphysema  
  
2) Clinical decision making:  
  
 Exercise evaluation and prescription for pulmonary rehabilitation  
 Evaluation for impairment-disability  
 Evaluation for lung, heart-lung transplantation  
  
 **LIMITATIONS:**  
  
Absolute and relative contraindications to exercise testing (field walking
tests) include:  
  
 ** _Absolute Contraindications_**  
  
 Acute myocardial infarction (3-5 days)  
 Unstable angina  
 Uncontrolled arrhythmias causing symptoms or hemodynamic compromise  
 Syncope  
 Active endocarditis  
 Acute myocarditis or pericarditis  
 Symptomatic severe aortic stenosis  
 Uncontrolled heart failure  
 Acute pulmonary embolus or pulmonary infarction  
 Thrombosis of lower extremities  
 Suspected dissecting aneurysm  
 Uncontrolled asthma  
 Pulmonary edema  
 SpO2 = 85% on room air  
 Acute respiratory failure  
 Acute non-cardiopulmonary disorder that may affect exercise performance or
be aggravated by exercise (i.e., infection, renal failure, thyrotoxicosis)  
 Mental impairment leading to inability to cooperate with the testing  
  
 ** _Relative Contraindications_**  
  
 Left main coronary artery stenosis or its equivalent  
 Moderate stenotic valvular heart disease  
 Severe untreated arterial hypertension at rest (200mmHg systolic, 120mmHg
diastolic)  
 Tachyarrythmias or bradyarrythmias  
 High degree atrioventricular block  
 Hypertrophic cardiomyopathy  
 Significant pulmonary hypertension  
 Advanced or complicated pregnancies  
 Electrolyte abnormalities  
 Orthopedic impairment that prevents walking