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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 cardiac computed tomographic angiography (CCTA), also known as computed tomography 
(CT) of the heart and coronary arteries or multidetector computed cardiac tomography (MDCT), is considered 
reasonable and necessary for the evaluation of suspected symptomatic coronary artery disease (CAD) and for 
the detection of structural and morphologic intra- and extra-cardiac conditions. 
 
Use of a CCTA is expected to avoid diagnostic cardiac catheterization. If high pre-test probability of CAD 
exists, this A/B MAC expects the patient to undergo invasive coronary angiography with appropriate 
percutaneous coronary intervention. 
 
To establish CCTA medical necessity, your case must meet at least 1 indication in the following 2 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 echocardiogram (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 CT and cardiac magnetic resonance imaging (MRI). 
 
** Uninterpretable EKG refers to EKGs with resting ST segment depression greater than or equal to 0.10 mV, 
complete left bundle branch block, pre-excitation or paced rhythm. 
 
3. Evaluation of intracardiac structures for suspected coronary anomalies. 
 
Suspected Cardiac Structural/Morphologic Anomalies 
 
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 echo, 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 3-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. 
 
This information can be found under Local Coverage Determination (LCD) Cardiac Computed Tomography & 
Angiography (CCTA) (L33423). 
 
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.