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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 say that Noninvasive Fractional Flow Reserve (FFRCT) 
 
Noninvasive fractional flow reserve deduced from computed tomography (FFRCT) involves computer-assisted 
processing of coronary computed tomography angiography (CCTA) images to estimate changes in blood 
pressure inside coronary arteries that have partial blockages, with the goal of determining how severely the 
blockages impede blood flow to the heart. FFRCT is a post-processing software for the clinical quantitative and 
qualitative analysis of previously acquired computed tomography (CT) Digital Imaging and Communications 
in Medicine (DICOM) data for clinically stable symptomatic patients with coronary artery disease (CAD). 
FFRCT analysis is intended to support the functional evaluation of CAD. The results of this analysis are 
provided to support qualified clinicians to aid in the evaluation and assessment of coronary arteries. 
 
United States (U.S.) Food and Drug Administration (FDA) approved non-invasive calculated coronary 
fractional flow reserve (FFRCT) technology derived from CCTA may be reasonable and necessary to guide 
qualified-provider decisions about the use of invasive coronary angiography (ICA) in clinically stable 
symptomatic patients with CAD of unknown functional significance, a technically adequate CCTA AND the 
following criteria: 
 
Intermediate risk* patients with acute or stable chest pain and no known coronary artery disease, with coronary 
artery stenosis of 40-90% in proximal or middle coronary artery on CCTA 
 
OR 
 
Intermediate risk with acute chest pain and known non-obstructive (less than 50 percent) CAD with findings of 
coronary artery stenosis of 40-90% in a proximal or middle coronary artery on CCTA 
 
OR 
 
Stable nonobstructive coronary artery disease (less than 50 percent stenosis) with persistent symptoms 
requiring further test, and findings of 40-90 percent stenosis on CCTA  
AND 
 
Not in conjunction with stress testing (unless CCTA was not sufficient quality for FFRCT and an alternative 
study is needed) 
 
FFRCT testing is not reasonable and therefore not covered for patients with the following conditions: 
 
    Bare metal intracoronary stent 
    Prosthetic valves 
    Heart transplantation 
    Recent prior myocardial infarction (MI) within 30 days 
    Suspicion for acute coronary syndrome (where acute MI or unstable angina have not been ruled out) 
    Patients with prior pacemaker or internal defibrillator lead implantation 
    Post coronary artery bypass surgery 
    Newly diagnosed systolic heart failure with no prior left heart catheterization 
    Non-obstructive CAD (less than 50 percent stenosis in all major epicardial vessels) on prior CCTA or prior 
catheterization, performed in last 12 months in the absence of a new symptom complex 
    *If turnaround times may impact prompt clinical care decisions 
 
*Intermediate and high-risk is as defined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline 
for the Evaluation and Diagnosis of Chest Pain27 
 
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 (for example. greater 
than 90 percent) are present, this study is not medically necessary, as the patient should proceed to 
catheterization. Similarly, low-grade stenoses (less than 40 percent) 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) for Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart 
Disease (L38278). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.