Appeal type: unknown
Decision: unknown

 
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 
 
Indications: 
 
    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. 
 
    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. 
 
    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. 
 
    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). 
 
    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. 
 
    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. 
 
    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. 
 
    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. 
 
    The test may be considered medically necessary in patients status post revascularization procedures who 
present with recurrent symptoms not clearly identifiable as ischemic. 
 
You can find this information in Medicare's 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.