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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 Medicare National Coverage
Determinations Manual, Section 220.1(A).
The rules say Indications:
CCTA used as an alternative to invasive angiography and stress testing. For patients with anginal symptoms,
patients with unclear stress tests results, patients in whom the stress test result contradicts the clinical
assessment, to determine the patency of coronary artery bypass grafts, as an alternative when cardiac
catheterization is impossible or carries a high risk, to rule out stenosis before non-coronary cardiac surgery
such as valve replacement or resection of tumors, and clarifying unclear finding after invasive angiography.
CCTA used to assess patients suspected of having a congenital coronary anomaly of great vessels, cardiac
chambers and valves. It is often used after an anomaly has been identified following a different test such as
prior invasive coronary angiogram. CCTA is used to decide if surgery is indicated and for surgical planning.
CCTA used to evaluate acute chest pain in the emergency department (ED). The rationale is to quickly triage
patients in order to rule out coronary artery disease as a possible cause of symptoms. Many will present with a
normal electrocardiogram and myocardial enzymes.
CCTA used to assess coronary or pulmonary venous anatomy. Coronary mapping is primarily for presurgical
planning such as pacemaker lead placement in the lateral coronary vein to resynchronize cardiac
contraction in patients with heart failure, or guiding biventricular pacemaker placement. Pulmonary vein
anatomy can vary from patient to patient. Pulmonary vein mapping is primarily for catheter ablation which can
isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation,
or help eliminate procedural complications.
CCTA used to assess etiology with new onset heart failure for evaluation of coronary arteries.
Limitations:
The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
The test will be considered not medically necessary if the anticipated results are not expected to provide
new, additional information to that already previously obtained from other tests (such as stress myocardial
perfusion images or cardiac ultrasound). New or additional information should facilitate the management
decision, not merely add a new layer of testing.
The test will be considered not medically necessary if pretest evaluation indicates that the patient would
require invasive cardiac angiography for further diagnosis or for therapeutic intervention.
The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if
there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that
would diminish the interpretive value. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.)
Coverage is limited to devices that process thin, high resolution slices (1mm or less). The multi-detector
scanners must have at least 64 slices per rotation capability.
The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician
experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable
service.
All studies must be ordered by the physician/qualified non-physician practitioner treating the
patient and who will use the results of the test in the management of the patient.
The test must be performed under the direct supervision of a physician, similar to the stress myocardial
perfusion imaging.
This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery
examination. There is no extension of coverage of EBT based on this policy.
Quantitative calcium scoring is not a covered service and will be denied as not medically necessary. Calcium
scoring reported in isolation is considered a screening service. When performed in association with CT
angiography, there is neither separate nor additional included reimbursement for the calcium scoring.
Atrial fibrillation or atrial flutter alone is not an indication; atrial fibrillation or atrial flutter with planned
ablation therapy is allowed.
You can find this information in Medicare's Local Coverage Determination (LCD): Coronary Computed
Tomography Angiography (CCTA) (L35121) and Local Coverage Article: Billing and Coding: Coronary
Computed Tomography Angiography (CCTA) (A57552).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.