Aetna · Clinical coverage policy

Aetna Cardiac CT and Calcium Scoring coverage criteria

Aetna CPB 0228 covers cardiac CT, coronary CT angiography (CCTA with 64-slice or greater scanners), coronary artery calcium scoring, CT fractional flow reserve, and FDA-cleared CCTA plaque quantification only for specific listed indications — chiefly ruling out obstructive coronary disease in symptomatic or selected at-risk persons, pre-operative cardiac/non-cardiac assessment, evaluating coronary anomalies, valve/structural and congenital heart conditions, and calcium-score screening limited to diabetics 40+ or persons at intermediate 10-year cardiac risk. The key gate is pre-test probability and meeting the criteria for each indication; screening of asymptomatic low-risk persons, scanners under 64-slice, and use outside the listed indications are considered experimental/investigational, with several patient factors (BMI over 40, uncontrolled heart rate or arrhythmia, prior Agatston over 1000) treated as contraindications. The bulletin states no precertification requirement.

Policy CPB 0228 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0228

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0228 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Cardiac CT and Calcium Scoring (CPT 75571), and what gets it denied?

Path
Aetna CPB 0228 covers cardiac CT, coronary CT angiography (CCTA with 64-slice or greater scanners), coronary artery calcium scoring, CT fractional flow reserve, and FDA-cleared CCTA plaque quantification only for specific listed indications — chiefly ruling out obstructive coronary disease in symptomatic or selected at-risk persons, pre-operative cardiac/non-cardiac assessment, evaluating coronary anomalies, valve/structural and congenital heart conditions, and calcium-score screening limited to diabetics 40+ or persons at intermediate 10-year cardiac risk. The key gate is pre-test probability and meeting the criteria for each indication; screening of asymptomatic low-risk persons, scanners under 64-slice, and use outside the listed indications are considered experimental/investigational, with several patient factors (BMI over 40, uncontrolled heart rate or arrhythmia, prior Agatston over 1000) treated as contraindications. The bulletin states no precertification requirement. Coverage criteria include: CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in SYMPTOMATIC persons with low or intermediate pre-test probability of CAD/ASCVD by Framingham risk scoring, Pooled Cohort Equations, or ACC criteria; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in persons with low or intermediate pre-test probability of CAD/ASCVD (by Framingham/Pooled Cohort/ACC criteria) WITH a positive stress test (>=1 mm ST segment depression); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of ASYMPTOMATIC persons at intermediate pre-test probability of CHD/ASCVD (by Framingham or Pooled Cohort Equations) who have an equivocal or uninterpretable exercise or pharmacological stress test, OR have resting ECG changes (LBBB, pathologic q-waves, RBBB with LAFB) in which CAD is a possible etiology; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment of persons scheduled for high-risk non-cardiac surgery where imaging stress test or invasive coronary angiography is being deferred unless absolutely necessary (high-risk defined by ACC as: emergent operations especially in elderly; aortic and major vascular surgeries; peripheral vascular surgeries; and prolonged surgical procedures with large fluid shifts and/or blood loss involving abdomen and thorax); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment for planned non-coronary cardiac surgeries (including valvular heart disease, congenital heart disease, and pericardial disease), in lieu of cardiac catheterization as the initial imaging study, in persons with low or intermediate pretest risk of obstructive CAD; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Detection and delineation of suspected coronary anomalies in young persons (less than 40 years of age) with suggestive symptoms (e.g., angina, syncope, arrhythmia, exertional dyspnea without other known etiology in children and adults; dyspnea, tachypnea, wheezing, periods of pallor, irritability, diaphoresis, poor feeding and failure to thrive in infants); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of in-stent stenosis; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Calculation of fractional flow reserve (FFR-CT) for persons with coronary CTA showing coronary artery disease of uncertain functional significance or non-diagnostic results; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of coronary ectasia; CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of persons needing biventricular pacemakers to accurately identify coronary veins for lead placement; CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation (pre- and post-ablation); CCTA for preoperative assessment of the aortic valve annulus prior to anticipated transcatheter aortic valve replacement (TAVR) — Medically necessary; CCTA for evaluation of aortic erosion in symptomatic members (e.g., chest pain) who have been treated for atrial septal defect with an occlusive device — Medically necessary; CCTA plaque quantification or coronary plaque analysis using data from CCTA — Medically necessary when ALL of the following are met: (1) the plaque quantification and/or analysis platform has been FDA-cleared (e.g., Cleerly coronary report, HeartFlow AI-QCPA); AND (2) the member has acute or stable chest pain with no known CAD; AND (3) the member has had a current CCTA and the results indicate ONE of these risk categories — Intermediate risk, CAD-RADS 1, CAD-RADS 2, or CAD-RADS 3 (NOT indicated for CAD-RADS 4, 5, and/or N); AND (4) physical examination and other cardiac testing (e.g., electrocardiogram, laboratory testing) are negative or inconclusive for acute coronary syndrome; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Anomalous pulmonary venous drainage; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Assessment of anatomy of left atrial appendage (LAA) prior to placement of LAA occlusion device; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of other complex congenital heart diseases; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of sinus venosum atrial-septal defect; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of suspected native or prosthetic cardiac valve dysfunction when echocardiographic imaging is inconclusive or there is suspicion for paravalvular abscess formation; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Kawasaki's disease; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart diseases; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Pulmonary outflow tract obstruction; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Suspected or known Marfan's syndrome; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Symptomatic post heart transplant recipients; Calcium scoring — Single calcium scoring (by low-dose multi-slice CT angiography, ultrafast (electron-beam) CT, or spiral (helical) CT) for SCREENING is medically necessary for: Asymptomatic persons age 40 years and older with diabetes; OR Asymptomatic persons with an intermediate (10% to 20%) 10-year risk of cardiac events based on Framingham Risk Scoring or Pooled Cohort Equations; Calcium scoring — Repeat calcium scoring is medically necessary only if ALL are met: (1) member's most recent coronary artery calcium (CAC) scan result was zero; AND (2) member's most recent CAC scan was at least 5 years ago; AND (3) discovery of coronary calcium would change management; Calcium scoring — Medically necessary: Calcium scoring by means of low-dose CT angiography for persons who meet criteria for diagnostic cardiac CT angiography, to assess whether an adequate image of the coronary arteries can be obtained; Calcium scoring — Medically necessary: Calcium scoring of the aortic valve in the setting of persons with suspected paradoxical low-flow, low-gradient symptomatic severe aortic stenosis when transthoracic echocardiography is inconclusive. Applies to 5 codes: 75571, 75572, 75573, 75574, 75580.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: NOT medically necessary: Radiological computer-assisted prioritization / artificial intelligence (AI) software (e.g., Nanox.AI's HealthCCSng) to aid in identification of cardiovascular disease during CT scanning of the chest — the software does not provide diagnostic information beyond triage and prioritization of radiological medical images and should not be used in place of full member evaluation or relied upon to make or confirm diagnosis; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with body mass index (BMI) greater than 40 (except when 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized); Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with inability to image at desired heart rate (under 80 beats/min), despite beta blocker administration; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons in atrial fibrillation (except when rate-controlled and 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized) or with other significant arrhythmia; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with extensive coronary calcification by plain film or with prior Agatston score greater than 1000; Experimental/investigational/unproven: Cardiac CT angiography using less than 64-slice scanners; Experimental/investigational/unproven: Cardiac CT angiography for prediction of adverse events in individuals with coronary artery bypass graft (CABG); Experimental/investigational/unproven: Ca-Ri Heart (Caristo Diagnostics); Experimental/investigational/unproven: Combined coronary CT angiography (CCTA) and dynamic CT myocardial perfusion for evaluation of coronary artery stenosis; Experimental/investigational/unproven: Coronary CT angiography for screening of asymptomatic persons (including routine testing of asymptomatic heart transplant recipients); Experimental/investigational/unproven: Coronary CT angiography for evaluation of atherosclerotic burden; Experimental/investigational/unproven: Coronary CT angiography for evaluation of persons at high pre-test probability of coronary artery disease; Experimental/investigational/unproven: Coronary CT angiography for identification of vulnerable plaques; Experimental/investigational/unproven: Coronary CT angiography for monitoring of atheroma burden; Experimental/investigational/unproven: Coronary CT angiography for all other indications (e.g., atrial angiosarcoma); Experimental/investigational/unproven: Coronary CT angiography for assessment of coronary atherosclerosis in asymptomatic diabetics who do not otherwise meet the above criteria for CT coronary angiography; Experimental/investigational/unproven: Calcium scoring (e.g., with ultrafast (electron-beam) CT, spiral (helical) CT, and multi-slice CT) for all other indications; Experimental/investigational/unproven: Evaluation of iliac calcium score by CTA as a marker of coronary calcification and atherosclerotic risk; Experimental/investigational/unproven: Serial or repeat calcium scoring; Experimental/investigational/unproven: Ultra-high resolution CCTA with photon counting for evaluation of intra-luminal stents, smaller coronary segments, and lesions with heavy calcification. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0228 — Cardiac CT and Calcium Scoring

Coverage criteria

  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in SYMPTOMATIC persons with low or intermediate pre-test probability of CAD/ASCVD by Framingham risk scoring, Pooled Cohort Equations, or ACC criteria
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in persons with low or intermediate pre-test probability of CAD/ASCVD (by Framingham/Pooled Cohort/ACC criteria) WITH a positive stress test (>=1 mm ST segment depression)
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of ASYMPTOMATIC persons at intermediate pre-test probability of CHD/ASCVD (by Framingham or Pooled Cohort Equations) who have an equivocal or uninterpretable exercise or pharmacological stress test, OR have resting ECG changes (LBBB, pathologic q-waves, RBBB with LAFB) in which CAD is a possible etiology
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment of persons scheduled for high-risk non-cardiac surgery where imaging stress test or invasive coronary angiography is being deferred unless absolutely necessary (high-risk defined by ACC as: emergent operations especially in elderly; aortic and major vascular surgeries; peripheral vascular surgeries; and prolonged surgical procedures with large fluid shifts and/or blood loss involving abdomen and thorax)
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment for planned non-coronary cardiac surgeries (including valvular heart disease, congenital heart disease, and pericardial disease), in lieu of cardiac catheterization as the initial imaging study, in persons with low or intermediate pretest risk of obstructive CAD
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Detection and delineation of suspected coronary anomalies in young persons (less than 40 years of age) with suggestive symptoms (e.g., angina, syncope, arrhythmia, exertional dyspnea without other known etiology in children and adults; dyspnea, tachypnea, wheezing, periods of pallor, irritability, diaphoresis, poor feeding and failure to thrive in infants)
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of in-stent stenosis
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Calculation of fractional flow reserve (FFR-CT) for persons with coronary CTA showing coronary artery disease of uncertain functional significance or non-diagnostic results
  • CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of coronary ectasia
  • CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of persons needing biventricular pacemakers to accurately identify coronary veins for lead placement
  • CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation (pre- and post-ablation)
  • CCTA for preoperative assessment of the aortic valve annulus prior to anticipated transcatheter aortic valve replacement (TAVR) — Medically necessary
  • CCTA for evaluation of aortic erosion in symptomatic members (e.g., chest pain) who have been treated for atrial septal defect with an occlusive device — Medically necessary
  • CCTA plaque quantification or coronary plaque analysis using data from CCTA — Medically necessary when ALL of the following are met: (1) the plaque quantification and/or analysis platform has been FDA-cleared (e.g., Cleerly coronary report, HeartFlow AI-QCPA); AND (2) the member has acute or stable chest pain with no known CAD; AND (3) the member has had a current CCTA and the results indicate ONE of these risk categories — Intermediate risk, CAD-RADS 1, CAD-RADS 2, or CAD-RADS 3 (NOT indicated for CAD-RADS 4, 5, and/or N); AND (4) physical examination and other cardiac testing (e.g., electrocardiogram, laboratory testing) are negative or inconclusive for acute coronary syndrome
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Anomalous pulmonary venous drainage
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Assessment of anatomy of left atrial appendage (LAA) prior to placement of LAA occlusion device
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of other complex congenital heart diseases
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of sinus venosum atrial-septal defect
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of suspected native or prosthetic cardiac valve dysfunction when echocardiographic imaging is inconclusive or there is suspicion for paravalvular abscess formation
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Kawasaki's disease
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart diseases
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Pulmonary outflow tract obstruction
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Suspected or known Marfan's syndrome
  • Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Symptomatic post heart transplant recipients
  • Calcium scoring — Single calcium scoring (by low-dose multi-slice CT angiography, ultrafast (electron-beam) CT, or spiral (helical) CT) for SCREENING is medically necessary for: Asymptomatic persons age 40 years and older with diabetes; OR Asymptomatic persons with an intermediate (10% to 20%) 10-year risk of cardiac events based on Framingham Risk Scoring or Pooled Cohort Equations
  • Calcium scoring — Repeat calcium scoring is medically necessary only if ALL are met: (1) member's most recent coronary artery calcium (CAC) scan result was zero; AND (2) member's most recent CAC scan was at least 5 years ago; AND (3) discovery of coronary calcium would change management
  • Calcium scoring — Medically necessary: Calcium scoring by means of low-dose CT angiography for persons who meet criteria for diagnostic cardiac CT angiography, to assess whether an adequate image of the coronary arteries can be obtained
  • Calcium scoring — Medically necessary: Calcium scoring of the aortic valve in the setting of persons with suspected paradoxical low-flow, low-gradient symptomatic severe aortic stenosis when transthoracic echocardiography is inconclusive

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Cardiac CT and Calcium Scoring (CPT 75571), and what gets it denied?
Aetna CPB 0228 covers cardiac CT, coronary CT angiography (CCTA with 64-slice or greater scanners), coronary artery calcium scoring, CT fractional flow reserve, and FDA-cleared CCTA plaque quantification only for specific listed indications — chiefly ruling out obstructive coronary disease in symptomatic or selected at-risk persons, pre-operative cardiac/non-cardiac assessment, evaluating coronary anomalies, valve/structural and congenital heart conditions, and calcium-score screening limited to diabetics 40+ or persons at intermediate 10-year cardiac risk. The key gate is pre-test probability and meeting the criteria for each indication; screening of asymptomatic low-risk persons, scanners under 64-slice, and use outside the listed indications are considered experimental/investigational, with several patient factors (BMI over 40, uncontrolled heart rate or arrhythmia, prior Agatston over 1000) treated as contraindications. The bulletin states no precertification requirement. Coverage criteria include: CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in SYMPTOMATIC persons with low or intermediate pre-test probability of CAD/ASCVD by Framingham risk scoring, Pooled Cohort Equations, or ACC criteria; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Rule out obstructive coronary stenosis in persons with low or intermediate pre-test probability of CAD/ASCVD (by Framingham/Pooled Cohort/ACC criteria) WITH a positive stress test (>=1 mm ST segment depression); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of ASYMPTOMATIC persons at intermediate pre-test probability of CHD/ASCVD (by Framingham or Pooled Cohort Equations) who have an equivocal or uninterpretable exercise or pharmacological stress test, OR have resting ECG changes (LBBB, pathologic q-waves, RBBB with LAFB) in which CAD is a possible etiology; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment of persons scheduled for high-risk non-cardiac surgery where imaging stress test or invasive coronary angiography is being deferred unless absolutely necessary (high-risk defined by ACC as: emergent operations especially in elderly; aortic and major vascular surgeries; peripheral vascular surgeries; and prolonged surgical procedures with large fluid shifts and/or blood loss involving abdomen and thorax); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Pre-operative assessment for planned non-coronary cardiac surgeries (including valvular heart disease, congenital heart disease, and pericardial disease), in lieu of cardiac catheterization as the initial imaging study, in persons with low or intermediate pretest risk of obstructive CAD; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Detection and delineation of suspected coronary anomalies in young persons (less than 40 years of age) with suggestive symptoms (e.g., angina, syncope, arrhythmia, exertional dyspnea without other known etiology in children and adults; dyspnea, tachypnea, wheezing, periods of pallor, irritability, diaphoresis, poor feeding and failure to thrive in infants); CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of in-stent stenosis; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Calculation of fractional flow reserve (FFR-CT) for persons with coronary CTA showing coronary artery disease of uncertain functional significance or non-diagnostic results; CCTA of coronary arteries using 64-slice or greater — Medically necessary: Evaluation of coronary ectasia; CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of persons needing biventricular pacemakers to accurately identify coronary veins for lead placement; CCTA of cardiac morphology for pulmonary vein mapping — Medically necessary: Evaluation of pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation (pre- and post-ablation); CCTA for preoperative assessment of the aortic valve annulus prior to anticipated transcatheter aortic valve replacement (TAVR) — Medically necessary; CCTA for evaluation of aortic erosion in symptomatic members (e.g., chest pain) who have been treated for atrial septal defect with an occlusive device — Medically necessary; CCTA plaque quantification or coronary plaque analysis using data from CCTA — Medically necessary when ALL of the following are met: (1) the plaque quantification and/or analysis platform has been FDA-cleared (e.g., Cleerly coronary report, HeartFlow AI-QCPA); AND (2) the member has acute or stable chest pain with no known CAD; AND (3) the member has had a current CCTA and the results indicate ONE of these risk categories — Intermediate risk, CAD-RADS 1, CAD-RADS 2, or CAD-RADS 3 (NOT indicated for CAD-RADS 4, 5, and/or N); AND (4) physical examination and other cardiac testing (e.g., electrocardiogram, laboratory testing) are negative or inconclusive for acute coronary syndrome; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Anomalous pulmonary venous drainage; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Assessment of anatomy of left atrial appendage (LAA) prior to placement of LAA occlusion device; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of other complex congenital heart diseases; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of sinus venosum atrial-septal defect; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Evaluation of suspected native or prosthetic cardiac valve dysfunction when echocardiographic imaging is inconclusive or there is suspicion for paravalvular abscess formation; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Kawasaki's disease; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart diseases; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Pulmonary outflow tract obstruction; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Suspected or known Marfan's syndrome; Cardiac CT for evaluating cardiac structure and morphology — Medically necessary: Symptomatic post heart transplant recipients; Calcium scoring — Single calcium scoring (by low-dose multi-slice CT angiography, ultrafast (electron-beam) CT, or spiral (helical) CT) for SCREENING is medically necessary for: Asymptomatic persons age 40 years and older with diabetes; OR Asymptomatic persons with an intermediate (10% to 20%) 10-year risk of cardiac events based on Framingham Risk Scoring or Pooled Cohort Equations; Calcium scoring — Repeat calcium scoring is medically necessary only if ALL are met: (1) member's most recent coronary artery calcium (CAC) scan result was zero; AND (2) member's most recent CAC scan was at least 5 years ago; AND (3) discovery of coronary calcium would change management; Calcium scoring — Medically necessary: Calcium scoring by means of low-dose CT angiography for persons who meet criteria for diagnostic cardiac CT angiography, to assess whether an adequate image of the coronary arteries can be obtained; Calcium scoring — Medically necessary: Calcium scoring of the aortic valve in the setting of persons with suspected paradoxical low-flow, low-gradient symptomatic severe aortic stenosis when transthoracic echocardiography is inconclusive. Applies to 5 codes: 75571, 75572, 75573, 75574, 75580. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: NOT medically necessary: Radiological computer-assisted prioritization / artificial intelligence (AI) software (e.g., Nanox.AI's HealthCCSng) to aid in identification of cardiovascular disease during CT scanning of the chest — the software does not provide diagnostic information beyond triage and prioritization of radiological medical images and should not be used in place of full member evaluation or relied upon to make or confirm diagnosis; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with body mass index (BMI) greater than 40 (except when 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized); Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with inability to image at desired heart rate (under 80 beats/min), despite beta blocker administration; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons in atrial fibrillation (except when rate-controlled and 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized) or with other significant arrhythmia; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with extensive coronary calcification by plain film or with prior Agatston score greater than 1000; Experimental/investigational/unproven: Cardiac CT angiography using less than 64-slice scanners; Experimental/investigational/unproven: Cardiac CT angiography for prediction of adverse events in individuals with coronary artery bypass graft (CABG); Experimental/investigational/unproven: Ca-Ri Heart (Caristo Diagnostics); Experimental/investigational/unproven: Combined coronary CT angiography (CCTA) and dynamic CT myocardial perfusion for evaluation of coronary artery stenosis; Experimental/investigational/unproven: Coronary CT angiography for screening of asymptomatic persons (including routine testing of asymptomatic heart transplant recipients); Experimental/investigational/unproven: Coronary CT angiography for evaluation of atherosclerotic burden; Experimental/investigational/unproven: Coronary CT angiography for evaluation of persons at high pre-test probability of coronary artery disease; Experimental/investigational/unproven: Coronary CT angiography for identification of vulnerable plaques; Experimental/investigational/unproven: Coronary CT angiography for monitoring of atheroma burden; Experimental/investigational/unproven: Coronary CT angiography for all other indications (e.g., atrial angiosarcoma); Experimental/investigational/unproven: Coronary CT angiography for assessment of coronary atherosclerosis in asymptomatic diabetics who do not otherwise meet the above criteria for CT coronary angiography; Experimental/investigational/unproven: Calcium scoring (e.g., with ultrafast (electron-beam) CT, spiral (helical) CT, and multi-slice CT) for all other indications; Experimental/investigational/unproven: Evaluation of iliac calcium score by CTA as a marker of coronary calcification and atherosclerotic risk; Experimental/investigational/unproven: Serial or repeat calcium scoring; Experimental/investigational/unproven: Ultra-high resolution CCTA with photon counting for evaluation of intra-luminal stents, smaller coronary segments, and lesions with heavy calcification. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Cardiac CT and Calcium Scoring?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Cardiac CT and Calcium Scoring?
Policy exclusions and limitations: NOT medically necessary: Radiological computer-assisted prioritization / artificial intelligence (AI) software (e.g., Nanox.AI's HealthCCSng) to aid in identification of cardiovascular disease during CT scanning of the chest — the software does not provide diagnostic information beyond triage and prioritization of radiological medical images and should not be used in place of full member evaluation or relied upon to make or confirm diagnosis; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with body mass index (BMI) greater than 40 (except when 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized); Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with inability to image at desired heart rate (under 80 beats/min), despite beta blocker administration; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons in atrial fibrillation (except when rate-controlled and 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized) or with other significant arrhythmia; Experimental/investigational/unproven (contraindication): Cardiac CT angiography for persons with extensive coronary calcification by plain film or with prior Agatston score greater than 1000; Experimental/investigational/unproven: Cardiac CT angiography using less than 64-slice scanners; Experimental/investigational/unproven: Cardiac CT angiography for prediction of adverse events in individuals with coronary artery bypass graft (CABG); Experimental/investigational/unproven: Ca-Ri Heart (Caristo Diagnostics); Experimental/investigational/unproven: Combined coronary CT angiography (CCTA) and dynamic CT myocardial perfusion for evaluation of coronary artery stenosis; Experimental/investigational/unproven: Coronary CT angiography for screening of asymptomatic persons (including routine testing of asymptomatic heart transplant recipients); Experimental/investigational/unproven: Coronary CT angiography for evaluation of atherosclerotic burden; Experimental/investigational/unproven: Coronary CT angiography for evaluation of persons at high pre-test probability of coronary artery disease; Experimental/investigational/unproven: Coronary CT angiography for identification of vulnerable plaques; Experimental/investigational/unproven: Coronary CT angiography for monitoring of atheroma burden; Experimental/investigational/unproven: Coronary CT angiography for all other indications (e.g., atrial angiosarcoma); Experimental/investigational/unproven: Coronary CT angiography for assessment of coronary atherosclerosis in asymptomatic diabetics who do not otherwise meet the above criteria for CT coronary angiography; Experimental/investigational/unproven: Calcium scoring (e.g., with ultrafast (electron-beam) CT, spiral (helical) CT, and multi-slice CT) for all other indications; Experimental/investigational/unproven: Evaluation of iliac calcium score by CTA as a marker of coronary calcification and atherosclerotic risk; Experimental/investigational/unproven: Serial or repeat calcium scoring; Experimental/investigational/unproven: Ultra-high resolution CCTA with photon counting for evaluation of intra-luminal stents, smaller coronary segments, and lesions with heavy calcification. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0228 — Cardiac CT and Calcium Scoring

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0228 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.