Is CT Calcium Scoring Covered by Medicare?

Medicare coverage for diagnostic tests like CT calcium scoring is a common concern for beneficiaries. This article clarifies whether and how CT calcium scoring is covered by Medicare, outlining procedural details and potential costs.

What is CT Calcium Scoring

CT calcium scoring is a non-invasive diagnostic procedure that utilizes computed tomography (CT) to assess calcified plaque within the coronary arteries. Specialized X-ray equipment generates detailed images of the heart, and the presence and density of calcium deposits are measured.

During the procedure, an individual lies on a movable table that slides into the CT scanner. Electrodes monitor heart activity to synchronize imaging with the heart’s rhythm. The scan takes only a few minutes, with the entire appointment lasting 10 to 15 minutes. This test generally does not require contrast material injection.

Medicare’s Coverage Rules

Medicare Part B covers outpatient diagnostic tests when medically necessary to diagnose or treat a specific medical condition. However, standalone quantitative calcium scoring is generally not covered by Medicare.

Medicare considers isolated CT calcium scoring a screening service, which is generally not covered unless statutorily mandated. Therefore, tests solely for general risk assessment in asymptomatic individuals usually fall outside Medicare’s coverage, reflecting its focus on existing medical problems rather than broad preventive screenings.

A CT scan of the heart may be covered if part of a comprehensive diagnostic evaluation for suspected symptomatic coronary artery disease (CAD). For example, a Coronary CT Angiography (CCTA) may be covered if medically necessary for evaluating patients with symptoms like chest pain or unexplained dyspnea, especially with intermediate pre-test probability of CAD. If calcium scoring is performed with a medically necessary CCTA, it is not separately reimbursed, as it is an incidental component of the primary diagnostic procedure.

Coverage for cardiac CT procedures requires adherence to specific technical and clinical criteria. The treating physician must order the test, intending to use results for patient management, and it must be performed under direct physician supervision. Medicare will not cover these tests if results are not expected to provide new information beyond other tests, or if invasive cardiac angiography is clearly required regardless of CT findings.

Your Out-of-Pocket Costs

Your financial responsibility for CT calcium scoring depends on Medicare coverage. If a medically necessary CT scan of the heart, including calcium scoring, is covered by Medicare Part B, you are responsible for certain out-of-pocket costs. For 2025, the annual Medicare Part B deductible is $257, which you must meet before Medicare begins to pay.

After the deductible, Medicare Part B generally pays 80% of the Medicare-approved amount for covered diagnostic services. You are responsible for the remaining 20% coinsurance. If the test is performed in a hospital outpatient setting, a co-payment may also apply. Many beneficiaries purchase Medicare Supplement Insurance (Medigap) to help cover these deductibles, coinsurance, and co-payments.

If CT calcium scoring is not medically necessary and therefore not covered by Medicare, you are responsible for the full cost. The out-of-pocket cost for a standalone CT calcium score can vary significantly, ranging from approximately $50 to $400, depending on the facility and geographic location. Always discuss potential costs with your healthcare provider and imaging facility beforehand. Understand your Medicare plan specifics, especially if you have a Medicare Advantage plan, to avoid unexpected charges.

Steps for Coverage and Billing

To pursue Medicare coverage for a CT cardiac scan, obtain a physician’s order clearly outlining the diagnostic test’s medical necessity. This order must align with Medicare’s criteria, indicating the scan is for diagnostic purposes related to a suspected medical condition, not general screening. Documentation from your treating physician supporting medical necessity is paramount for claim submission.

For Original Medicare (Parts A and B) beneficiaries, prior authorization is generally not required for most CT scans. However, Medicare Advantage (Part C) plans often require prior authorization for advanced imaging services. Check with your specific Medicare Advantage plan to understand their authorization processes, as failure to obtain prior approval can result in claim denials and full patient responsibility.

Once the test is performed, the healthcare provider or facility will submit a claim to Medicare. If Medicare denies coverage, beneficiaries have the right to appeal. The Medicare appeals process involves multiple levels, beginning with a redetermination request where you explain your disagreement and provide supporting medical evidence.

There are five appeal levels: reconsideration, an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, and ultimately, judicial review in federal court if the claim meets financial thresholds. Adhere to specified appeal timeframes, typically 120 days from the initial denial notice for Original Medicare.