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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 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). 
 
The rules say that to establish CCTA medical necessity, your case must meet at least one indication in the 
following two categories: 
 
Symptomatic (CAD) 
 
1. Evaluation of Acute Chest Pain, unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw 
pain) when there is: 
 
    Intermediate pre-test probability of CAD* and 
    No (electrocardiogram) EKG changes to suggest acute myocardial injury or ischemia and 
    Normal initial cardiac markers. 
    Patients with intermediate risk and a discordant clinical situation (e.g., ongoing ischemic symptoms, normal 
stress test). 
 
2. Evaluation of Chest Pain Syndrome when there is: 
 
    Intermediate pre-test probability of CAD* and 
    Uninterpretable EKG** or patient is unable to exercise or 
    Uninterpretable or equivocal stress test (exercise, perfusion or stress echo). 
 
*Intermediate pretest probability of CAD by age, gender and symptoms is between 10% and 90% as referenced 
in the American College of Coronary Foundation/American College of Radiology (ACCF/ACR) 2006 
appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. 
 
** Uninterpretable EKG refers to EKGs with resting ST segment depression greater than or equal to 0.10mV, 
complete left bundle branch block, pre-excitation or paced rhythm. 
 
3. Evaluation of intracardiac structures for suspected coronary anomalies. 
 
Suspected Cardiac Structural/Morphologic Anomolies 
 
1. Detection of intracardiac and extracardiac structures in: 
 
    Evaluation of cardiac mass (suspected tumor or thrombus) or 
    Evaluation of pericardial conditions (mass, constrictive pericarditis or complications of cardiac surgery) or 
    Patients with technically limited images from echocardiogram, magnetic resonance imaging (MRI) or 
transesophageal echocardiography (TEE). 
 
2. Detection of morphologic intracardiac and extracardiac structures for: 
 
    Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation. While 
data is limited for three dimensional (3D) reconstruction of the left atrium for ablations, there is broad 
consensus among cardiologists that these images, which are integrated and used in real-time in the procedure 
room to shorten procedure time, improve therapeutic success and enhance patient safety or 
    Non-invasive coronary vein mapping prior to placement of biventricular pacemaker or 
    Non-invasive coronary arterial mapping, including internal mammary artery, prior to repeat cardiac surgical 
revascularization or 
    Detection of complex congenital heart disease including anomalies of coronary circulation, great vessels and 
cardiac chamber and valves or 
    Evaluation of coronary arteries in patients with new onset heart failure to assess etiology. 
 
Limitations: 
 
1. Coverage of CCTA is limited to computed tomography (CT) devices that process thin, high resolution slices. 
Decreased resolution and slower rotation speeds result in a higher number of non-evaluable segments. At the 
current time, Medicare requires the multidetector scanner to have collimation of 0.625 mm or less and a 
rotational speed of 375 msec or less OR to have at least 64 slice detector design. Do not submit studies from 
scanners that do not meet these requirements. 
 
2. Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for 
quantitative evaluation of coronary calcium. This Local Coverage Determination (LCD) does not address 
Heartflow determinations. 
 
Ultrafast CT scan of the heart electron-beam tomography (EBT) or electron-beam computed tomography 
(EBCT) is not a covered service. 
 
3. Simultaneous exclusion of obstructive CAD, pulmonary embolism and aortic dissection (?triple rule-out?) in 
the emergency department is not covered. In order to optimize imaging of the right coronary artery (RCA), 
contrast must be cleared from the right sided chambers during acquisition, a process that leads to suboptimal 
contrast timing in the pulmonary arteries. Simultaneous rule-out of aortic pathology (at the low pitch needed to 
properly image the coronaries) mandates thicker slices in order to capture the total volume required in a 
reasonable breath hold. The increased slice thickness degrades coronary image quality. 
 
4.  CCTA patients must be able to lie still, follow breathing instructions and take nitroglycerin for coronary 
dilatation. 
 
5. Prior to the initiation of a CCTA, the physician must make an assessment of the anatomic location, degree 
and intensity of calcification and impact of the calcification on the utility of the test results.  CCTAs performed 
on patients with elevated quantitative calcium scores that preclude accurate assessment of coronary anatomy 
are not covered by Medicare. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Cardiac Computed 
Tomography & Angiography (CCTA) (L33423).
 
The rules say that screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
CMS 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.