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 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 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 the indications for cardiac computed tomography (CCT) and coronary computed tomography angiography (CCTA) are:  a. Patient presenting with chest pain syndrome.  These tests may be used in lieu of an imaging stress test. The clinician must have a high degree of suspicion that CAD is high on the differential diagnosis of the symptoms.  b. To facilitate the management decision of a patient with an equivocal stress test.  These tests might be chosen in select patients who have an equivocal stress (or stress imaging) test. The rationale is that a noninvasive coronary anatomic test (CCTA) allows an alternate method of assessing the coronary arteries, which would limit the number of negative invasive coronary angiograms.  c. When the recurrence of symptoms in patients with known coronary artery disease may be related to progression/exacerbation of underlying disease.  The use of these tests in this setting would be to evaluate the extent of previously diagnosed coronary artery disease. Patients with known disease may have had remote invasive angiography and/or stress testing to evaluate prior events or symptoms. New or recurrent symptoms may relate to a change in the coronary anatomy that can be assessed with these tests.  d. When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or dyspnea.     Coronary bypass grafts are relatively well seen with these tests. The rationale for the tests would be to determine the patency and severity of possible graft stenoses that may be the source of chest pain. Patients with prior intracoronary stents often present with recurrent chest pain. The rationale for these tests as an alternative to invasive angiography is to rule out in-stent restenosis as the cause of symptoms. (Accurate assessment of in-stent restenosis may be limited by the artifact caused by the stent material itself and the quality of the scan and scanner).  e. Suspected congenital anomalies of the coronary circulation.  These tests are used to assess patients suspected of having a congenital coronary anomaly. The cross-sectional nature of this technique allows one to determine accurately both the presence and possible future harm that could result from the anomaly. It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram. These tests are used to decide if surgery is indicated and for surgical planning.  f. The assessment of coronary or pulmonary venous anatomy.  This application of the tests for the coronary and pulmonary veins is primarily for pre-surgical planning. Coronary venous anatomy can be useful for the cardiologist who needs to place a pacemaker lead in the lateral coronary vein in order to resynchronize cardiac contraction in patients with heart failure. This may be helpful to guide biventricular pacemaker placement.  Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein catheter ablation can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation. The presence of a pulmonary venous anatomic map may help eliminate procedural complications and allow for the successful completion of the procedure.  g. The patient undergoing non-coronary artery cardiac surgery.  Certain patients who have non-coronary artery cardiac surgery (valve or ascending aortic surgery) may need a pre-operative invasive coronary angiogram. The surgical planning may also depend upon the exact location of the coronary arteries. The rationale for the use of CCTA in these patient subsets is to avoid potentially unnecessary invasive testing and still provide appropriate pre-surgical information.  h. The test may be medically necessary in patients presenting to the emergency room with complaints consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes.  i. The test may be considered medically necessary in patients status post revascularization procedures who present with recurrent symptoms not clearly identifiable as ischemic.  j. FFRCT - this test may be considered medically necessary when CCTA shows CAD of uncertain functional    significance, or is non-diagnostic and where the addition of functional information provided by FFRCT can help the physician determine which patient may require invasive evaluation and / or treatment.  You can find this rule in the Local Coverage Determination (LCD) - Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559) - Effective October 1, 2019.  The rules say that these tests are never covered for screening, i.e., in the absence of signs, symptoms or disease. These tests 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.  You can find this rule in the Local Coverage Determination (LCD) - Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (L33559) - Effective October 1, 2019.  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.