This document addresses the diagnostic indications for cardiac stress testing with electrocardiogram (also known as an ECG or EKG), which is a noninvasive diagnostic evaluation of the heart performed to assess suspected or known coronary artery disease (CAD). A cardiac stress test, also called a stress test, exercise electrocardiogram, treadmill test, graded exercise test, exercise electrocardiography, or stress ECG, is a test used to provide information about how the heart responds to exertion or induced stress. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while cardiac parameters are monitored, including ECG, heart rate, and blood pressure. For individuals who are unable to tolerate exercise, pharmacologic stress testing can be performed where medications, such as dobutamine or adenosine, are injected to induce cardiac stress.

Clinical Indications

Medically Necessary:

Cardiac stress testing with electrocardiogram is considered medically necessary as part of a coronary evaluation for ANY of the following indications (A through G): 

1. To diagnose obstructive coronary artery disease when either of the following are present (1 or 2):
   1. In adults with intermediate pretest probability of coronary artery disease on the basis of gender, age, and symptoms (see Table 1); or
   2. With vasospastic angina; or
2. For risk assessment and prognosis in symptomatic individuals or those with a prior history of coronary artery disease who meet any of the following (1 through 5):
   1. As part of initial evaluation of individuals with suspected or known coronary artery disease; or
   2. In individuals previously evaluated with stress testing with suspected or known coronary artery disease, now with significant change in clinical status; or
   3. Individuals with low risk unstable angina 8 to 12 hours after presentation who have been free of active ischemic or heart failure symptoms; or
   4. Individuals with intermediate risk unstable angina 2 to 3 days after presentation who have been free of active ischemic or heart failure symptoms; or
   5. Individuals with intermediate risk unstable angina who have initial cardiac markers that are normal, a repeat electrocardiogram without significant change, and cardiac markers 6 to 12 hours after the onset of symptoms that are normal and no other evidence of ischemia; or
3. Following a myocardial infarction for any of the following (1 through 4):
   1. Before discharge for prognostic assessment, activity prescription, and evaluation of medical therapy; or
   2. Early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the pre-discharge exercise test was not done; or
   3. Late after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the early exercise test was submaximal (symptom limited; about 3 to 6 weeks); or
   4. After discharge for activity counseling and/or exercise training as part of cardiac rehabilitation following a coronary revascularization procedure; or
4. With ventilatory gas analysis for any of the following (1, 2 or 3):
   1. Evaluation of exercise capacity and response to therapy in individuals with heart failure who are being considered for heart transplantation; or
   2. Assistance in the differentiation of cardiac versus pulmonary limitations as a cause of exercise-induced dyspnea or impaired exercise capacity; or
   3. Evaluation of exercise capacity when indicated for medical reasons in individuals in whom the estimates of exercise capacity from exercise test time or work rate are unreliable; or
5. In valvular heart disease with chronic aortic regurgitation, aortic valve stenosis or mitral valve regurgitation, for any of the following (1, 2, or 3):
   1. For assessment of functional capacity and symptomatic responses when there is a history of equivocal symptoms; or
   2. For evaluation of symptoms and functional capacity before participation in athletic activities; or
   3. For prognostic assessment before aortic valve or mitral valve replacement in asymptomatic or minimally symptomatic subjects with left ventricular dysfunction; or
6. Before and after a revascularization procedure for any of the following (1, 2, or 3):
   1. When there is demonstration of ischemia before revascularization; or
   2. For evaluation of recurrent symptoms that suggest ischemia after revascularization; or
   3. After discharge for activity counseling and/or exercise training as part of cardiac rehabilitation following coronary revascularization; or
7. For evaluation of heart rhythm disorders for any of the following (1, 2, or 3):
   1. For programming of rate-adaptive pacemakers; or
   2. For evaluation of known or suspected exercise-induced arrhythmias; or
   3. For evaluation of medical, surgical, or ablative therapy in individuals with exercise-induced arrhythmias, including atrial fibrillation.

Not Medically Necessary:

Cardiac stress testing with electrocardiogram is considered not medically necessary when the criteria are not met and for all other applications including, but not limited to, screening in individuals with low risk pretest probability of disease and in the absence of symptoms suspicious for cardiovascular disease.