Navigating medical billing complexities, especially for advanced diagnostic procedures, can be challenging. Whether an insurance plan covers a specific test, such as the one billed under Current Procedural Technology (CPT) Code 75571, depends entirely on the payer’s specific policy and the patient’s documented clinical status. Coverage is not universal, and a lack of preparation can lead to unexpected out-of-pocket costs. This article clarifies the factors that determine whether an insurer will pay for this diagnostic test.
Understanding CPT Code 75571
CPT Code 75571 represents a computed tomography (CT) scan of the heart performed without contrast material, including a quantitative evaluation of coronary artery calcium (CAC) scoring. This non-invasive imaging procedure measures the amount of calcified plaque buildup in the coronary arteries. The resulting Agatston score quantifies the total burden of calcium, which correlates with the extent of coronary artery disease (CAD). This test is distinct from Coronary Computed Tomography Angiography (CCTA), which requires intravenous contrast material and uses codes like CPT 75574. The primary application of the CAC score is to assess a patient’s risk of a future cardiovascular event and help physicians determine if preventive therapies, such as statin medication, should be initiated or intensified.
Criteria for Coverage Approval
The most important factor determining coverage for CPT 75571 is medical necessity, defined by specific clinical guidelines established by each insurance payer. Insurers maintain detailed documents, such as Local Coverage Determinations (LCDs) or Clinical Appropriateness Guidelines, that list the exact circumstances for coverage. CPT 75571 is often considered a screening tool when used in isolation. Many insurers, including Medicare, explicitly state that calcium scoring as a standalone screening service is not a covered benefit and will be denied as not medically necessary.
Coverage is often granted when the test is used for risk stratification in asymptomatic individuals who fall into an intermediate-risk category for CAD. For instance, some guidelines consider the procedure appropriate for adults aged 40 to 75 who have a 10-year Atherosclerotic Cardiovascular Disease (ASCVD) risk score between 5.0% and 19.9% and no documented history of CAD. The CAC score in these cases helps reclassify the patient’s risk, influencing the decision to start preventive treatment. Conversely, the procedure is denied for routine screening of asymptomatic patients with a low ASCVD risk or for patients already known to have CAD, as the results would not change the treatment plan.
The prescribing physician is responsible for documenting the patient’s symptoms and risk factors precisely to align with the payer’s guidelines. If documentation shows the test was performed purely for screening in an asymptomatic patient without intermediate-risk factors, the claim will likely be denied as investigational or not medically appropriate. Some payers also deny the claim if the patient has had a prior calcium score greater than zero or has had the procedure performed within the last five years. Coverage rests entirely on the specific clinical context and the accuracy of the medical record submitted to the insurer.
The Necessity of Prior Authorization
Even when the clinical situation meets the insurer’s medical necessity criteria, most insurance plans require Prior Authorization (PA) for advanced imaging procedures like CPT 75571. PA is an administrative requirement where the healthcare provider must submit documentation and receive official approval before performing the procedure. This process allows the payer to review medical records in advance to confirm the proposed service meets coverage guidelines. Failure to obtain a required PA is a common cause of claim denial or a substantial reduction in payment. If the provider proceeds without authorization, the patient may be held financially responsible for the entire cost of the service. The responsibility for initiating and securing the approval falls upon the ordering provider’s office.
Actionable Steps for Verifying Coverage
Patients should take proactive steps to confirm coverage before undergoing a test to prevent surprise billing. The first action is to contact the insurance company directly using the member services number on the insurance card. When speaking with a representative, the patient should specifically ask about coverage for CPT Code 75571 and confirm if the procedure is a covered benefit under their policy.
Key Verification Points
- Verify that both the facility where the scan will be performed and the ordering physician are in-network with the plan.
- Inquire about remaining annual deductible, co-payment, and co-insurance amounts.
- Record the date, time, and the name of the representative spoken to, along with a reference number for the call.
Addressing Claim Denials and Appeals
If a claim for CPT 75571 is denied, the first step is to carefully review the Explanation of Benefits (EOB) document sent by the insurer, which states the specific reason for the denial. Common reasons include a lack of medical necessity, failure to obtain prior authorization, or the procedure being considered a screening service. Patients have the right to appeal this decision, which typically involves a two-step process: an internal appeal followed by an external review.
The Appeal Process
The internal appeal requires the patient or provider to submit a formal request to the insurance company asking them to reconsider the decision, often within 180 days of the denial notice. This appeal must include additional clinical documentation, such as a letter from the physician, that strengthens the case for medical necessity by directly addressing the payer’s specific criteria. If the internal appeal is unsuccessful, the patient can request an external review, where an independent third party reviews the decision.