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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 a computed tomographic (CT) image is a display of the anatomy of a thin slice of the body 
developed from multiple x-ray absorption measurements made around the periphery of the body. Unlike 
conventional tomography, where the image of a thin section is created by blurring out the information from 
unwanted regions, the CT image is constructed mathematically using data arising only from the section of 
interest. Generating such an image is confined to cross sections of the anatomy that are oriented essentially 
perpendicular to the axial dimensions of the body. Reconstruction of the final image can be accomplished in 
any plane. 
 
Abdominal CT 
 
The CT of the abdomen extends from the dome of the diaphragm to the pelvic brim or pubic symphysis, 
depending upon whether one groups the pelvis with the abdomen or treats it separately. 
 
A CT scan of the abdomen will be considered medically reasonable and necessary under the following 
circumstances: 
 
- Evaluation of abdominal pain 
 
- Evaluation of known or suspected abdominal masses or fluid collections 
 
- Evaluation of primary or metastatic malignancies 
 
- Evaluation of abdominal inflammatory processes 
 
- Evaluation of abnormalities of abdominal vascular structures (Note: Medical necessity for CT angiography is 
not addressed in this LCD) 
 
- Evaluation of abdominal trauma 
 - Clarification of findings from other imaging studies of the abdomen or laboratory abnormalities suggesting 
abdominal pathology 
 
- Guidance for interventional diagnostic or therapeutic procedures within the abdomen 
 
- Treatment planning for radiation therapy 
 
- For patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or 
TAVR) provided that the patient has not undergone a CT of the abdomen within the preceding 60 days 
 
Pelvic CT 
 
The CT scan of the pelvic area includes all pelvic structures including the bladder, the prostate in males, 
ovaries, uterus, and uterine adnexa in females, and the lower retroperitoneum, and iliac lymph node chains. The 
CT scan of the pelvis is useful in evaluating cysts, tumors, masses, metastases to one or more of these organs, 
and iliac lymph nodes. Intravenous contrast material may be administered. 
 
A CT scan of the pelvis will be considered medically necessary and reasonable under the following 
circumstances: 
 
- Evaluation of cysts, tumors, or masses of the pelvic structure (i.e., that which lies at or below the pelvic brim 
or true pelvis) 
 
- Evaluation of metastasis of primary cancers to this region 
 
- Evaluation of inflammatory processes in this region 
 
- Evaluation of abnormalities of pelvic vascular structures 
 
- Evaluation of lymphadenopathies of this region 
 
- Evaluation of lower abdominal, generalized abdominal or pelvic pain 
 
- Evaluation of other genitourinary (GU) disorders in which the physician cannot make a diagnosis on physical 
examination and/or by ultrasound (US) 
 
- Evaluation of trauma to the pelvic structure/organs 
 
- Evaluation of the effectiveness of a radiation treatment plan 
 
- For patients being evaluated for potential TAVI or TAVR provided that the patient has not undergone a CT of 
the pelvis within the preceding 60 days. 
 
Intravenous contrast material may be administered with any of the above studies. 
 
In addition to the medical necessity requirements, the CT scan must be performed on a model of CT equipment 
that meets the following criteria: 
 
- The model must be known to the Food and Drug Administration (FDA); and 
 
- Must be in the full market release phase of development. 
 You can find this information under Local Coverage Determination (LCD) CT of the Abdomen and Pelvis 
(L34415). 
 
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.