0162-Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements

Dynamic List Information
Dynamic List Data
Issue Name
0162-Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements
Provider Type
Outpatient Hospital
MAC Jurisdiction
ALL A/B MACs
Date
2025-08-28
RAC Type
Approved

Description

Documentation will be reviewed to determine if Computed Tomography (CT) Coronary Angiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.

Affected Code(s)

CPT 75574 

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(7)- Routine physical checkups
3.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
4.    42 CFR §405.929- Post-Payment Review
5.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
6.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7.    42 CFR §405.986- Good Cause for Reopening  
8.    42 CFR §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
9.    42 CFR §411.15(a)(1)- Particular services excluded from coverage; Routine physical checkups
10.    Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations  §220.1- Computed Tomography (CT) §A- General, and §F- Computed Tomographic Angiography (CTA)
11.    Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions.
12.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
13.    CGS Local Coverage Determination LCD L33947- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised  10/05/2023
14.    CGS Local Coverage Article LCA A56451- Billing and Coding:  Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2016; Revised  11/16/2023
15.    First Coast Local Coverage Determination LCD L33282- Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries; Effective 10/01/2015; Revised 10/01/2019; Retired 2/23/2023
16.    First Coast Local Coverage Article LCA A57061- Billing and Coding: Computed Tomographic Angiography of the Chest, Heart, and Coronary Arteries; Effective 10/03/2018; Revised 10/01/2022; Retired 2/23/2023
17.    NGS Local Coverage Determination LCD L33559- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 4/01/2022
18.    NGS Local Coverage Article LCA A56737- Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 08/01/2019; Revised  10/01/2023
19.    Palmetto Local Coverage Determination LCD L33423- Cardiac Computed Tomography and Angiography (CCTA); Effective 10/01/2015; Revised  4/06/2023
20.    Palmetto Local Coverage Article LCA A56691- Billing and Coding: Cardiac Computed Tomography and Angiography (CCTA); Effective 07/11/2019; Revised  10/01/2023
21.    WPS Local Coverage Determination LCD L35121- Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 11/30/2023
22.    WPS Local Coverage Article LCA A57552-  Billing and Coding:  Coronary Computed Tomography Angiography (CCTA); Effective 11/28/2019; Revised  10/01/2023
23.    AMA CPT Codebook