Does Medicare Pay for a Coronary Calcium Scan?

A coronary calcium scan is an imaging test that assesses an individual’s risk for heart disease. It provides insight into the health of the coronary arteries.

Understanding the Coronary Calcium Scan

A coronary calcium scan, also known as cardiac calcium scoring, uses a computed tomography (CT) scan to measure calcium deposits in the heart’s arteries. These deposits mark plaque buildup, which can narrow arteries and increase the risk of heart-related events. The procedure is non-invasive.

The scan results are expressed as a calcium score, indicating the extent of calcified plaque. A score of zero suggests low risk, while higher scores signify more plaque and greater coronary artery disease risk. This information helps healthcare providers assess risk and guide preventive or treatment strategies.

Medicare Coverage for Coronary Calcium Scans

Medicare Part B generally covers diagnostic tests deemed medically necessary for diagnosing or treating a specific medical condition. However, Medicare typically does not cover coronary calcium scans for routine screening of individuals without heart disease symptoms. This is because the scan is considered a preventive or screening service rather than a diagnostic tool.

Medicare’s policy states that preventive and screening services are only covered if specifically mandated by statute. Coronary calcium scoring, when performed as a standalone screening service, is generally not a covered benefit and may be denied as not medically necessary.

Conditions for Coverage

A coronary calcium scan may be covered by Medicare if deemed medically necessary as part of a diagnostic workup. This medical necessity arises when ordered by a healthcare provider to diagnose or guide treatment for an existing heart condition, or due to specific symptoms. For example, if a patient presents with unexplained chest pain, a physician may order the scan.

Coverage may also extend to follow-up for a previously diagnosed heart condition, or when it provides new information influencing a management decision. A physician’s order and thorough documentation of medical necessity are crucial for potential coverage. Standard Medicare Part B deductibles and coinsurance typically apply, meaning beneficiaries are responsible for a portion of the approved cost.

Out-of-Pocket Costs and Alternatives

If Medicare does not cover a coronary calcium scan, beneficiaries are responsible for the full cost. The typical out-of-pocket cost for a coronary calcium scan when paid for privately can range from approximately $50 to $400. These self-pay rates vary based on location and facility.

Medicare covers several alternative methods for assessing cardiovascular risk as preventive services. These include routine blood pressure checks, cholesterol screenings, and physician consultations as part of annual wellness visits. These services provide valuable information for evaluating heart health and guiding preventive care.