Decision Considerations
Disease Protocols - Graded Exercise Stress Test Requirements

• If a plain GXT is required and is uninterpretable for any reason, a radionuclide GXT will then be required before further consideration
  • In patients with bundle branch blocks (BBB), LVH, or diffuse ST/T wave changes at rest, a stress echo or nuclear stress test will be required.
• GXT requirements:
  • 100% of predicted maximal heart rate (PMHR), unless medically contraindicated or prevented either by symptoms or medications;
  • Complete Stage 3 (equivalent to at least 9 minutes);
  • Studies of less than 85% of maximum predicted heart rate and less than 9 minutes of exercise (6 minutes for age 70 or greater) may serve a basis for denial; and
  • Beta blockers and calcium channel blockers (specifically diltiazem and verapamil) or digitalis preparations should be discontinued for 24-48 hours prior to testing (if not contraindicated and only with the consent of the treating physician) in order to obtain maximum heart rate.
    • If the GXT is done on beta blockers, calcium blockers, or digitalis medications, the applicant must provide explanation from the treating cardiologist as to why the medication(s) cannot be held.
• The worksheet with blood pressure/pulse recordings at various stages, interpretive report, and actual ECG tracings* must be submitted.
  • Tracings must include a rhythm strip;
  • A full 12-lead ECG recorded at rest - supine and standing. (Anything less than a full 12-lead will not be accepted); and
  • One or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5 minutes or until the tracings return to baseline level. *Computer generated, sample-cycle ECG tracings are unacceptable in lieu of the standard tracings. If submitted alone, this may result in deferment until this requirement is met.