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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 CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 220.1(A). The rules say that a CT scan of the abdomen will be considered medically reasonable and necessary under the following circumstances: Evaluation of abdominal pain Evaluation of known or suspected abdominal masses or fluid collections Evaluation of primary or metastatic malignancies Evaluation of abdominal inflammatory processes Evaluation of abnormalities of abdominal vascular structures (Note: Medical necessity for CT angiography is not addressed in this LCD) Evaluation of abdominal trauma Clarification of findings from other imaging studies of the abdomen or laboratory abnormalities suggesting abdominal pathology Guidance for interventional diagnostic or therapeutic procedures within the abdomen Treatment planning for radiation therapy For patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or TAVR) provided that the patient has not undergone a CT of the abdomen within the preceding 60 days NOTE: Plain and upright or lateral decubitus roentgenograms of the abdomen represent the basic screening tool in identifying abnormalities involving the abdomen. It is expected that the abdominal x-ray is used to evaluate patients who present with signs and symptoms suggestive of abdominal pathology prior to proceeding to a CT scan. Pelvic CT The CT scan of the pelvic area includes all pelvic structures including the bladder, the prostate in males,
ovaries, uterus, and uterine adnexa in females, and the lower retroperitoneum, and iliac lymph node chains. The CT scan of the pelvis is useful in evaluating cysts, tumors, masses, metastases to one or more of these organs, and iliac lymph nodes. Intravenous contrast material may be administered. A CT scan of the pelvis will be considered medically necessary and reasonable under the following circumstances: Evaluation of cysts, tumors, or masses of the pelvic structure (i.e., that which lies at or below the pelvic brim or true pelvis) Evaluation of metastasis of primary cancers to this region Evaluation of inflammatory processes in this region Evaluation of abnormalities of pelvic vascular structures Evaluation of lymphadenopathies of this region Evaluation of lower abdominal, generalized abdominal or pelvic pain Evaluation of other genitourinary (GU) disorders in which the physician cannot make a diagnosis on physical examination and/or by ultrasound (US) Evaluation of trauma to the pelvic structure/organs Evaluation of the effectiveness of a radiation treatment plan For patients being evaluated for potential TAVI or TAVR provided that the patient has not undergone a CT of the pelvis within the preceding 60 days. Intravenous contrast material may be administered with any of the above studies. In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment that meets the following criteria: The model must be known to the Food and Drug Administration (FDA); and Must be in the full market release phase of development. You can find this information in Medicare's Local Coverage Determination (LCD): CT of the Abdomen and Pelvis (L34415).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.