CPT code 75571 represents the Coronary Artery Calcium (CAC) Scoring test, which is a non-invasive tool used to assess future heart disease risk. Whether insurance covers this procedure is complex, as coverage is highly variable. It largely depends on why the test is being performed and who provides the insurance coverage. Because the CAC score often falls into a regulatory gray area between a routine check and a necessary diagnostic test, patients frequently face unexpected out-of-pocket costs. Successfully navigating coverage requires understanding the procedure and the differing criteria insurers use to determine payment.
Understanding Coronary Calcium Scoring
CPT code 75571 identifies a computed tomography (CT) scan of the heart performed without contrast material to quantitatively evaluate coronary calcium. This non-invasive imaging test measures calcified plaque in the coronary arteries, which is a direct sign of underlying atherosclerosis (hardening of the arteries). The result is quantified as an Agatston score, ranging from zero to several thousand. A higher score indicates a greater atherosclerotic burden and a higher long-term risk of a major cardiovascular event, such as a heart attack.
The procedure is quick, typically taking less than 10 minutes, and uses a relatively low dose of radiation. The test is primarily used as a risk stratifier for asymptomatic individuals with an intermediate risk profile for heart disease based on traditional factors like cholesterol and blood pressure. By visualizing subclinical disease, the CAC score helps clinicians decide whether to intensify preventive therapies, such as statin medication. Code 75571 should only be used when the calcium scoring is performed as a stand-alone procedure, separate from a full CT coronary angiography (CTA).
Coverage Determinants: Preventive Screening Versus Medical Necessity
The primary obstacle to insurance coverage for CPT 75571 is the distinction insurers make between preventive screening and medical necessity. Most health plans cover procedures deemed medically necessary to diagnose or treat a current disease, symptom, or injury. They often exclude procedures classified as routine screening or those considered “investigational” for asymptomatic patients.
When the Coronary Calcium Score is ordered for an individual with no symptoms of heart disease, the insurer typically classifies the test as an elective screening. Since the patient is asymptomatic, the test predicts a future problem rather than diagnosing a current one, often falling outside standard medical benefits. Insurers frequently deny the claim for CPT 75571, reasoning that there is insufficient evidence that it improves long-term health outcomes for all asymptomatic populations.
To meet the criteria for medical necessity, the patient generally needs specific symptoms or a high-risk profile where the test result will immediately change the clinical management plan. For example, some insurers cover the test for asymptomatic patients with an intermediate 10-year risk of atherosclerotic cardiovascular disease (ASCVD) if the score determines whether to initiate statin therapy. A zero score or a high score provides actionable data that alters the treatment path. Coverage may also be granted if the calcium score is performed before a full CT angiography (CTA) to determine if the patient has too much calcium to proceed with the contrast-enhanced study.
Payer Policies: Medicare and Private Insurance Trends
Payer policies on CPT 75571 show a clear division. Medicare, which covers a large segment of the population over 65, generally adheres to strict non-coverage for screening. Local Coverage Determinations (LCDs) issued by Medicare administrative contractors explicitly state that quantitative calcium scoring is not a covered service and will be denied as not medically necessary when reported in isolation.
This non-coverage stems from Medicare’s foundational policy that preventive and screening services are only covered if mandated by statute, which CPT 75571 is not. Consequently, a patient with Medicare who receives this test without a clear, covered diagnostic indication should expect the claim to be denied. In this scenario, the patient becomes fully responsible for the cost of the test.
Private insurance trends are more varied but often follow a similar, restrictive pattern, frequently labeling the procedure as “investigational” or “experimental” for general screening. Many large private payers deny CPT 75571 for all indications, except for a few narrowly defined, high-risk scenarios. These exceptions often align with professional cardiology guidelines, allowing coverage for asymptomatic adults aged 40 to 75 who fall into an intermediate-risk category (typically a 10-year ASCVD risk between 5% and 20%). If the patient does not meet these specified age and intermediate-risk criteria, or if the test is not ordered to make a definitive treatment decision, private insurance is likely to deny the claim.
Actionable Steps to Verify Your Coverage and Estimate Costs
Request Pre-Authorization
Given the high likelihood of non-coverage, taking specific steps before the procedure is necessary to avoid surprise bills. The first step is to request pre-authorization from your insurance provider. Even if your physician believes the test is medically necessary, the insurer must agree and issue an authorization number to guarantee payment.
Verify Codes and Diagnosis
Contact your insurance company directly using the member services number on your card and specifically ask about coverage for CPT code 75571. You must inquire about the specific diagnosis code (ICD-10 code) your physician is using, as the diagnosis often determines coverage. A diagnosis code indicating a screening test on an asymptomatic patient will likely result in a denial.
Compare Self-Pay Options
Contact the imaging facility’s billing department to request an estimated cost for the procedure, including the facility fee and the professional fee for the radiologist’s interpretation. Since CPT 75571 is often not covered, many imaging centers offer a “self-pay” or “cash price” that is significantly lower than the rate billed to insurance. Comparing the estimated out-of-pocket cost for a denied claim versus the self-pay price helps determine the most economical path forward.