The Coronary Artery Calcium (CAC) scan is a non-invasive imaging procedure that provides valuable insight into a person’s risk for cardiovascular disease. The test uses a computed tomography (CT) scanner to detect and quantify calcified plaque within the coronary arteries. The presence of calcium in these arteries is a direct marker of atherosclerosis, or plaque buildup. This article details how Medicare, the federal health insurance program for people 65 or older, addresses coverage for this specific heart health test.
What the Coronary Artery Calcium Scan Measures
The CAC scan works by taking multiple X-ray images of the heart, with a computer then analyzing the images for calcium deposits. The result is expressed as an Agatston score, which is a number based on the total area and density of the calcified plaque detected. A score of zero means no calcium is present, suggesting a low likelihood of a heart attack in the near future.
Higher scores correlate with a greater burden of atherosclerosis and a higher risk of a cardiac event. For instance, a score between 100 and 300 suggests moderate calcium deposits and a relatively elevated risk of a heart attack. A score exceeding 400 signifies extensive disease and a high risk, prompting physicians to tailor preventive strategies. This score helps refine risk assessment, particularly for individuals whose risk is uncertain based on traditional factors.
Medicare’s Policy on Preventive Screening Tests
Original Medicare, specifically Part B, does not routinely cover the Coronary Artery Calcium scan when it is used purely for screening or risk stratification in a person who has no symptoms. The test is generally classified by the Centers for Medicare & Medicaid Services (CMS) as a preventive screening test for asymptomatic individuals. This policy is based on the distinction between screening tests, which look for potential problems in healthy people, and diagnostic tests, which are ordered to investigate existing symptoms or a known medical problem.
Since the CAC scan is not included in the list of approved Medicare preventive services, the general rule is that it is not covered for most healthy seniors. Coverage is often determined by National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs), which establish the conditions under which a service is considered medically necessary. When a test is not covered by an NCD, a Medicare Administrative Contractor (MAC) can establish an LCD for its region, but the CAC scan remains largely non-covered nationally.
Clinical Scenarios That May Allow Coverage
Coverage for a CAC scan under Medicare may shift if the test is ordered for a diagnostic purpose. The test may be covered if a patient presents with unexplained symptoms, such as atypical or non-cardiac chest pain, and the physician needs the scan to determine the cause. In this context, the scan moves from being a screening tool to a diagnostic tool, which aligns with Medicare’s coverage criteria.
For coverage to be considered, the physician must document that the test is medically necessary to guide a treatment plan, and that the results will directly alter the course of care. For example, a physician may justify the scan to decide whether to start or intensify statin therapy in a patient whose risk is intermediate based on other factors. The presence of calcium in the arteries might push a physician to prescribe more aggressive treatment.
Understanding Out-of-Pocket Costs and Alternatives
When Medicare is expected to deny payment for a CAC scan, the provider must issue an Advance Beneficiary Notice of Noncoverage (ABN). This notice informs the beneficiary that they will be responsible for the cost of the service if Medicare denies the claim. The ABN allows the patient to make an informed decision to proceed with the test and accept the financial liability.
Because the CAC scan is typically a self-pay procedure, many hospitals and imaging centers offer heavily discounted cash prices to patients. The typical out-of-pocket cost for a CAC scan generally ranges from about $100 to $400, depending on the facility and geographic location. For those seeking covered alternatives for heart health assessment, Medicare Part B does cover other services, such as a cardiovascular screening blood test to check cholesterol and lipid levels.