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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 a Cardiac Computed Tomography (CCT) and Coronary Computed Tomography 
Angiography (CCTA) scans are covered if the following limitations are met: 
 
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. 
 
Limitations: 
a. These tests are never covered for screening, i.e., in the absence of signs, symptoms or disease. 
b. 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. 
c. These tests will be considered not medically necessary if it is anticipated that the patient would require 
invasive cardiac angiography for further diagnosis or for therapeutic intervention. (e.g., angina decubitus, 
unstable angina, Prinzmetal angina, etc.) 
d. These tests may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation 
if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that 
would diminish the interpretive value. 
e. The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician 
experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable 
service. 
f. All studies must be ordered by the physician/qualified non-physician practitioner treating the patient and who 
will use the results of the test in the management of the patient. 
g. CCTA must be performed under the direct supervision of a physician. 
h. This LCD does not address electron beam tomography (EBT) technology or Ultrafast computed tomography 
(CT) for coronary artery examination. There is no extension of coverage of EBT based on this policy. 
i. Quantitative calcium scoring is not a covered service and will be denied as not medically necessary. Calcium 
scoring reported in isolation is considered a screening service. When performed in association with CT 
angiography, there is neither separate nor additional included reimbursement for the calcium scoring. 
j. Acceptable Levels of Competence for Performance and Interpretation: Providers submitting claims for these 
tests must demonstrate proficiency and training in performing the tests according to the following standards. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Local Coverage Determination (LCD): Cardiac Computed Tomography (CCT) and Coronary 
Computed Tomography Angiography (CCTA) (L33559). 
 
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.