A Coronary Artery Calcium (CAC) scan is a non-invasive computed tomography (CT) test that creates detailed images of the heart’s arteries. This procedure quantifies the amount of calcified plaque buildup, which is a direct measure of atherosclerosis. The resulting score, known as the Agatston score, helps physicians assess an individual’s risk for a future heart attack or coronary artery disease events. Understanding how Medicare handles this specialized screening is important for beneficiaries considering this assessment of heart health risk.
Medicare’s Policy on Preventive Heart Scans
Medicare Part B generally does not cover the cost of a Coronary Artery Calcium scan when it is performed as a screening tool for asymptomatic individuals. The Centers for Medicare & Medicaid Services (CMS) has not approved the CAC scan as a routine covered preventive cardiovascular disease screening service. This policy is based on the distinction between purely preventive screening and diagnostic testing.
A foundational principle of Original Medicare coverage is that a service must be considered “medically necessary” for the diagnosis or treatment of an illness or injury. Since the CAC scan is typically used for risk stratification in people who do not yet have symptoms of heart disease, it falls into the category of preventive screening. The scan’s primary use is to identify those at intermediate risk who may benefit from aggressive therapy, such as statin medication.
Medicare Part B does cover certain cardiovascular disease screenings, such as blood tests for cholesterol and lipid levels, but the CAC scan is specifically excluded when performed in isolation for risk assessment. If a patient presents with symptoms suggesting coronary artery disease, such as unexplained chest pain, a physician may order a diagnostic CT scan of the heart. In this specific, diagnostic context, Part B may cover the test because it meets the medical necessity criteria.
How Different Medicare Plans Handle Coverage
The determination of coverage for a CAC scan depends heavily on the type of Medicare plan a beneficiary has. For those enrolled in Original Medicare (Parts A and B), the scan is almost universally a non-covered service when used for asymptomatic screening. Original Medicare’s strict adherence to the “medically necessary” standard means beneficiaries should expect to pay the full cost out-of-pocket for preventive purposes.
The situation is different for beneficiaries enrolled in a Medicare Advantage Plan, also known as Medicare Part C. These plans are offered by private insurance companies approved by Medicare and must provide all the benefits of Original Medicare. However, they often include additional benefits not covered by Part A and Part B.
Some Medicare Advantage plans may offer the CAC scan as a supplemental benefit. These benefits vary significantly between plans, even within the same geographic area. A plan may cover the scan partially or fully, or offer a discounted rate as part of a wellness package. Beneficiaries must review their specific plan’s Evidence of Coverage document or contact the plan directly to confirm if the CAC scan is included as a covered benefit.
Navigating Out-of-Pocket Costs
Since the CAC scan is typically not covered by Original Medicare, beneficiaries are responsible for the entire expense if they choose to have the procedure. The out-of-pocket cost for a self-pay CAC scan varies widely depending on the facility, the geographic location, and whether the provider offers self-pay rates. Generally, the cost ranges from approximately $100 to $400, with many facilities offering flat-rate pricing for patients paying cash.
If a provider believes Medicare is likely to deny payment for a service, they must issue an Advance Beneficiary Notice of Noncoverage (ABN). This notice informs the Original Medicare beneficiary that Medicare is not expected to pay, explains the reason for the denial, and confirms the patient will be responsible for the cost if they proceed. Providers often use this waiver to ensure the patient understands their financial liability.
Patients considering the scan should proactively inquire about the facility’s self-pay price before scheduling the appointment. Many imaging centers and hospitals offer significant discounts for patients who pay in full at the time of service, which can be considerably lower than the rate billed to an insurance company. Comparing prices between different local providers can help secure the most affordable option.