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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 MDCT angiography of the chest for non-cardiac assessment will be considered medically 
reasonable and necessary for the following signs or symptoms of disease: 
 Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli; 
 Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio-
venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart; 
 Assessment of suspected congenital anomalies of the heart or great vessels; and 
 Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or 
ill defined, but is critical to the diagnosis. 
MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary 
for the following signs or symptoms of disease: 
 Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a 
low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid 
performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be 
performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If 
a high pre-test probability of disease exists, as if the patient has known CAD, it is assumed the patient 
would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting 
could be performed at the same time). 
 Assessment of suspected congenital anomalies of coronary circulation. 
 Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging, 
if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test 
probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary 
angiography would be done in addition to a subsequent coronary catheterization and angiogram). 
 Evaluation of pulmonary veins prior to arrhythmia ablation procedures 
 Evaluation of cardiac veins prior to insertion of biventricular pacemaker 
You can find this rule in the Local Coverage Determination (LCD): Computed Tomographic Angiography of 
the Chest, Heart and Coronary Arteries (L33282) effective October 1, 2019. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.