A Coronary Calcium Scan (CCS) is a non-invasive computed tomography (CT) procedure that measures calcified plaque in the coronary arteries. The procedure produces an Agatston score, which predicts future cardiovascular events like heart attack or stroke. The primary purpose of the CCS is to improve cardiovascular risk stratification for individuals who do not yet show symptoms of heart disease. Insurance coverage for the scan is complex, highly variable, and rarely automatic, depending heavily on specific risk factors and the type of insurance plan.
Medical Necessity and Coverage Criteria
Insurance coverage for a CCS hinges on establishing medical necessity, requiring the test to be classified as a covered diagnostic tool rather than a non-covered preventative screening. Major medical organizations recommend the CCS for asymptomatic individuals in an intermediate cardiovascular risk category. This intermediate risk is defined as having a 10-year risk for atherosclerotic cardiovascular disease (ASCVD) between 7.5% and 20%, based on pooled cohort equations.
The scan is generally not covered for people at very low risk, as a low score is unlikely to change their treatment plan. It is also often not covered for those already at very high risk, such as patients with existing coronary artery disease, because the results will not alter the established need for aggressive treatment. The CCS is most useful for intermediate-risk individuals, as a high calcium score can reclassify them to a high-risk category, prompting a change in treatment like starting statin therapy.
A referring physician must document specific intermediate risk factors, such as a strong family history of premature heart disease, high cholesterol, or hypertension, to justify the request. The procedure is billed using the Current Procedural Terminology (CPT) code 75571. Without documented factors placing the patient in the intermediate risk group, the insurer will likely consider the procedure a preventative screening and issue a denial.
Coverage Differences by Payer Type
The likelihood of coverage for a CCS differs significantly based on the type of insurance payer. Original Medicare Part B generally does not cover the CCS as a routine preventative screening test. Since the Centers for Medicare & Medicaid Services (CMS) has not classified the scan as “reasonable and necessary,” most beneficiaries pay the full cost out of pocket.
Coverage is extremely rare under Medicaid plans, as the CCS is not broadly considered an essential health benefit. Some Medicare Advantage plans, offered by private companies, may offer coverage as an added benefit, but this is highly plan-dependent.
Commercial insurance carriers often follow the guidelines of major cardiology organizations, which may allow for coverage. Coverage from these private payers is most often approved for asymptomatic patients meeting the intermediate risk definition, though this varies widely by policy and state regulations. Even when criteria are met, many commercial plans require formal pre-authorization to confirm medical necessity before the scan.
Navigating Denials and Cash Pricing
When an insurer denies coverage for a CCS, the patient and physician may file an appeal. This requires the referring physician to provide stronger documentation detailing the patient’s specific risk factors and explaining how the calcium score guides a treatment decision, such as initiating statin medication. A denial often occurs because the procedure is categorized as a screening test rather than a diagnostic one.
Due to frequent coverage denial, the CCS is commonly offered as a low-cost, self-pay service. The cash-pay price for the procedure typically ranges from $100 to $400, often falling between $100 and $150. This cash price is significantly lower than the rate the facility bills to an insurance company. Patients should always inquire about the self-pay rate before scheduling the scan, especially if they have a high-deductible health plan or anticipate a denial.
In some cases, facilities charge as low as $49 for the scan, making the cash-pay option a practical choice for many individuals seeking this health information. Choosing the cash option can bypass the lengthy insurance approval and appeals process entirely.