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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 CT scans are covered if there is literature to support its use for the patients 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 multi-detector computed tomography (MDCT) angiography of the chest for non-cardiac 
assessment will be considered medically reasonable and necessary for the following signs or symptoms of 
disease:  
 Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli; 
 Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio-
venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart; 
 Assessment of suspected congenital anomalies of the heart or great vessels; and 
 Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or 
ill defined, but is critical to the diagnosis. 
MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary 
for the following signs or symptoms of disease: 
 Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a 
low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid 
performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be 
performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If 
a high pre-test probability of disease exists, as if the patient has known CAD, it is assumed the patient 
would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting 
could be performed at the same time). 
 Assessment of suspected congenital anomalies of coronary circulation. 
 Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging, 
if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test 
probability of disease exists, as if the patient has known CAD, it is not expected that computed 
tomography (CT) coronary angiography would be done in addition to a subsequent coronary 
catheterization and angiogram).  Evaluation of pulmonary veins prior to arrhythmia ablation procedures 
 Evaluation of cardiac veins prior to insertion of biventricular pacemaker 
 
Limitations 
 The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. 
 The test is never covered for patients with stable coronary artery disease without any significant change 
in signs or symptoms. 
 The selection of the test should be made within the context of other testing modalities so that the 
resulting information facilitates the management decision and does not merely add an additional layer 
of testing. The test may be denied, on post-pay review, as not medically necessary when used for 
cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive 
calcification that would diminish the interpretive value. 
 Coverage of this modality for coronary artery assessment is limited to devices that process thin, high-
resolution slices (0.75 mm or less) A multidetector scanner must have a row of at least 32 detectors. For 
non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices 
or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less. 
 The administration of beta-blockers and/or other medications and the monitoring of the patient by a 
physician during the MDCT are not separately payable services. 
 All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or 
qualified non-physician provider must be present during testing whenever cardioactive agents or 
contrast agents are administered (direct physician supervision). Ideally, this supervising physician will 
be experienced in this procedure and advanced cardiovascular life support (ACLS)-certified. 
 Electron Beam Technology provides high temporal resolution and enables quantitative assessment of 
the coronary artery calcium, but because of limited spatial resolution as a result of the limited z axis 
resolution (slice thickness=3.0 mm), it does not permit direct visualization in multi-reformation of the 
whole coronary system. Therefore, CT angiography of the heart is not considered medically necessary 
when performed with an electron beam tomography (EBT) scanner. 
 
You can find this information in the Local Coverage Determination (LCD): Computed Tomographic 
Angiography of the Chest, Heart, and Coronary Arteries (L33282). 
 
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.