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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. 
FDA-approved Fractional Flow Reserve Computed Tomography (FFRct) technology may be considered 
reasonable and necessary in the management of patients with: 
a. Intermediate-risk* patients with acute or stable chest pain with no known history coronary artery stenosis 
with finding of 40-90% in proximal or middle coronary artery on Coronary computed tomography 
angiography (CCTA) OR 
b. Intermediate risk* patients with acute chest pain and known non-obstructive (less than 50%) Coronary artery 
disease (CAD) coronary artery stenosis with finding of 40-90% stenosis in proximal or middle coronary artery 
on CCTA
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 OR 
c. Stable non-obstructive coronary artery disease (less than 50% stenosis) with persistent** symptoms 
requiring further test, and finding of 40-90% stenosis on CCTA
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AND 
Not in conjunction with stress testing* (unless CCTA was not sufficient quality for FFRCT, and an alternative 
study needed)  
*Intermediate and high-risk and stress test as defined in the 2021 
AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
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**Persistent symptoms are unacceptable ischemia-related symptoms despite maximally tolerated medical 
therapy. 
FFRct is not considered reasonable in the following clinical circumstances: 
1. Prior placement of prosthetic valves 
2. Prior placement of grafts in coronary bypass surgery 3. Suspicion of acute coronary syndrome (where myocardial infarction (MI) or unstable angina have not 
been ruled out) 
4. Intracoronary metallic stent 
5. Status post-heart transplantation 
6. Recent MI (30 days or less) 
7. Prior pacemaker or defibrillator lead placement 
8. Newly diagnosed systolic heart failure, with no prior left heart catherization 
9. Left main coronary artery disease with Intermediated Coronary Stenosis (lumen reduction less than or 
equal to 40%) 
10. Non-obstructing stenosis (less than 50% of all major epicardial vessels) on CTA or catheterization in 
the past twelve months, in the absence of a new symptom complex. 
11. If turnaround times may impact prompt clinical care decisions 
This service should be performed in patients with stable coronary symptoms. It should not be performed until 
after the base study (CCTA) has been completed and interpreted. If higher grade stenoses (i.e. greater than 
90%) are present, this study is not medically necessary, as the patient should proceed to catheterization. 
Similarly, low-grade stenoses (less than 40%) do not require additional confirmatory data. This should be 
performed as an alternative to stress testing.  
You can find this information in the Local Coverage Determination (LCD): Non-Invasive Fractional Flow 
Reserve (FFR) for Ischemic Heart Disease (L38613). 
 
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.