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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 state 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 a CT scan of the neck must be found medically appropriate considering the patients 
symptoms and preliminary diagnosis. A CT scan is considered medically reasonable and necessary when the 
physical diagnostic exam is medically appropriate to address the patients symptoms and diagnosis.  
 
CT scans are used effectively in the following situations or conditions: 
1. Patients who are not suitable candidates for Magnetic Resonance Imaging (MRI) evaluation: 
a. Because of a pacemaker or intracranial metallic objects 
b. Because of extreme obesity 
c. Because of an inability to lie still 
2. Patients whose condition requires the visualization of fine bone detail or calcification 
3. Patients with the following conditions: 
a. Acute Central Nervous System (CNS) Hemorrhage 
b. Strokes or encephalomalacia 
c. New onset seizures, particularly if a focal component is present (contrast agent is appropriate for 
these patients) 
d. Intracranial lesions large enough to cause increased intracranial pressure (CT scan is useful to 
determine gross margins between tumor and edematous brain) 
 
There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in 
individual cases it may be determined that use of a CT scan as the initial diagnostic test is not reasonable and 
necessary because it is not supported by the patients symptoms or complaints as stated on the claim. 
 
CT imaging has not been useful in general for the evaluation of headache or dizziness and should be reserved 
for the patient whose presentation indicates a focal problem or who has experienced a significant change in 
symptomatology.  
 
 
 A CT scan for the diagnosis of headache can be allowed for the following: 
1. After a head injury to rule out intracranial bleeding 
2. Headache unusual in duration (greater than two weeks) not responding to medical therapy, to rule out 
the possibility of a tumor 
3. A headache characterized by sudden onset and severity to rule out the possibility of an aneurysm, 
bleeding and/or arteriovenous malformation 
 
A CT scan may be ordered without contrast, with contrast, or without contrast followed by contrast. Contrast 
administration is not without risk to the patient, and for some conditions, adds little to no benefit to the patient. 
The general indications for use of contrast CT scanning are to: 
1. Assess perfusion (e.g. cerebrovascular accident) 
2. Characterize a specific lesion 
3. Detect defects in blood/brain barrier (e.g. infarct, tumor, infection, vasculitis) 
4. Detect neovascularity (tumor), and 
5. For staging of known lung cancer, breast cancer, and lymphomas likely to metastasize early to the brain 
 
Intravenous contrast generally adds no information to CT scan done secondary to head trauma. Additional 
symptoms suggesting a possible intracranial bleed may justify use of contrast. These symptoms should be 
documented in the medical record, and if appropriate, included in the diagnostic codes listed on the claim. 
More than one contrast CT scan per episode of illness adds no information with the following exceptions: 
1. Cerebrovascular accident (CVA) 
2. Non-traumatic hemorrhage 
3. Transient Ischemic Attack (TIA) 
4. Post-operative scan for residual tumor or post-operative complication 
5. Known brain tumor/metastases with a change in mental status or other evidence of CNS change 
 
Coverage is limited to those CT machines that have received pre-market approval by the Food and Drug 
Administration (FDA). Such units must be operated within the parameters specified by the approval. 
 
You can find these rules in the Local Coverage Determination (LCD) for MRI and CT Scans of the Head and 
Neck (L35175). 
 
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.