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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, Publication 100-03, Medicare National Coverage Determinations Manual, Section 220.1(A). The rules say that CT colonography/virtual colonoscopy requires colonic preparation similar to that required for instrument (fiberoptic, video) colonoscopy, as well as air insufflation to achieve colonic distention. You can find this rule in the Local Coverage Determination (LCD) - Virtual Colonoscopy (CT Colonography) (L34055) - Effective September 30, 2021. The rules say that virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope proximally, and a repeat attempt is not indicated. Virtual colonoscopy is intended for use in pre-operative planning only when imaging of the non-visualized colon proximal to the obstruction is medically necessary in making decisions involving the approach to the patient. Incomplete colonoscopy must be due to one of the following: 1. An obstructing neoplasm 2. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior surgery, radiation, or diverticular disease. 3. Extrinsic compression. 4. Patient safety. There are few absolute contraindications to instrument colonoscopy. Relative contraindications do not create medical necessity for using virtual colonoscopy as a screening procedure, and the above indications must still be met. You can find this rule in the Local Coverage Determination (LCD) - Virtual Colonoscopy (CT Colonography) (L34055) - Effective September 30, 2021. The rules say that the relative contraindications to instrument colonoscopy may be indications for virtual colonoscopy if well documented in the medical record and the patient's primary physician and the colonoscopist agree on the increased risk to the patient: 1. Severe coagulopathy
Long-term anticoagulation 3. Increased sedation risk (such as from severe chronic obstructive pulmonary disease, or previous anesthesia adverse reaction) You can find this rule in the Local Coverage Determination (LCD) - Virtual Colonoscopy (CT Colonography) (L34055) - Effective September 30, 2021. The rules say that virtual colonoscopy is not covered when used for screening, or in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease. It is not covered when used as an alternative to instrument colonoscopy for screening or in the absence of signs or symptoms of disease. It is not covered following incomplete colonoscopy if the reason for the colonoscopy is other than one of those described above. You can find this rule in the Local Coverage Determination (LCD) - Virtual Colonoscopy (CT Colonography) (L34055) - Effective September 30, 2021.
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.