Appeal type: unknown
Decision: unknown

 
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 state that computed tomography (CT) 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 CT is expected to avoid performing 
diagnostic cardiac catheterization. CT 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 CT 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 
 
The coverage limitations are: 
- The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. 
- The test is never covered for patients with stable coronary artery disease without any significant change 
in signs or symptoms. 
- The selection of the test should be made within the context of other testing modalities so that the 
resulting information facilitates the management decision, and does not merely add an additional layer 
of testing. The test may be denied, on post-pay review, as not medically necessary when used for 
cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive 
calcification that would diminish the interpretive value. 
- Coverage of this modality for coronary artery assessment is limited to devices that process thin, high-
resolution slices (0.75 mm or less) A multidetector scanner must have a row of at least 32 detectors. For non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices 
or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less. 
- The administration of beta-blockers and/or other medications and the monitoring of the patient by a 
physician during the CT are not separately payable services. 
- All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or 
qualified non-physician provider must be present during testing whenever cardioactive agents or 
contrast agents are administered (direct physician supervision). Ideally, this supervising physician will 
be experienced in this procedure and ACLS-certified. 
- Electron Beam Technology (EBT) provides high temporal resolution and enables quantitative 
assessment of the coronary artery calcium, but because of limited spatial resolution as a result of the 
limited z axis resolution (slice thickness equals 3.0 mm), it does not permit direct visualization in multi-
reformation of the whole coronary system. Therefore, CT angiography of the heart is not considered 
medically necessary when performed with an EBT scanner. 
 
You can find these rules in Local Coverage Determination (LCD) Computed Tomographic Angiography of the 
Chest, Heart, and Coronary Arteries (L33282). 
 
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.