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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 state that Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography 
(CCTA) can be covered for the following indications: 
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. 
 
The rules also say that these tests are never covered for screening purposes.  
 
You can find this information in the 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.