Why would a calcium coronary score, also known as a coronary artery calcium (CAC) scan, be denied by an insurance company for an asymptomatic patient without significant risk factors for coronary artery disease?

Why Insurance Companies Deny Coronary Artery Calcium Scoring

Insurance companies typically deny coronary artery calcium (CAC) scoring for asymptomatic patients without significant risk factors because current guidelines do not support its use in low-risk populations, where the test provides minimal clinical utility and does not change management decisions. 1

Evidence-Based Indications for CAC Scoring

The appropriate use of CAC scoring is narrowly defined by major cardiology societies:

• CAC scoring is recommended only for asymptomatic adults aged 40-75 years with intermediate (7.5-20% 10-year ASCVD risk) or borderline (5-7.5% 10-year ASCVD risk) cardiovascular disease risk when decisions about preventive interventions are uncertain. 1, 2

• Selected low-risk adults with specific risk-enhancing factors (family history of premature CAD, metabolic syndrome, chronic inflammatory conditions, elevated lipoprotein(a) >50 mg/dL) may be considered for CAC scoring. 1, 2

• CAC scoring is NOT appropriate for truly low-risk asymptomatic patients (<5% 10-year ASCVD risk) because the test does not provide actionable information that changes management. 1

Why Low-Risk Patients Get Denied

Insurance companies deny CAC scoring in low-risk asymptomatic patients for several evidence-based reasons:

• In low-risk populations, only 2% have detectable atherosclerotic plaque on imaging, making the test yield extremely low. 1

• The 2013 expert consensus on appropriate use criteria did not deem imaging for evaluating ischemic heart disease in asymptomatic low-risk patients to be appropriate. 1

• Low-risk patients with CAC = 0 (which is the most likely result) already have excellent prognosis with annual mortality rates <0.5%, so the test provides no additional clinical value. 3

• Even when CAC > 0 is found in low-risk patients, the absolute risk remains low enough that aggressive interventions may not be warranted, making the test clinically unhelpful. 1

Common Documentation Pitfalls Leading to Denial

Insurance denials often occur due to inadequate documentation of appropriate indications:

• Failure to document calculated 10-year ASCVD risk score showing intermediate or borderline risk (must show actual percentage, not just "elevated cholesterol"). 2

• Ordering CAC in patients under age 40 (men) or under age 50 (women), where calcification prevalence is too low to be useful. 1

• Requesting CAC for symptomatic patients with chest pain, where the test is inappropriate because CAC = 0 does not exclude obstructive disease (7-38% of symptomatic patients with CAC = 0 have obstructive CAD). 3, 4

• Using vague ICD-10 codes rather than specific codes that justify intermediate-risk screening (Z13.6 for cardiovascular screening, Z82.49 for family history, E78.5 for hyperlipidemia). 2

Algorithm for Appropriate CAC Ordering to Avoid Denial

Step 1: Calculate 10-year ASCVD risk using the Pooled Cohort Equation

• If <5% (low risk): CAC not indicated, will be denied 1
• If 5-7.5% (borderline): CAC may be appropriate if risk-enhancing factors present 1
• If 7.5-20% (intermediate): CAC is appropriate, especially when statin decision uncertain 1
• If ≥20% (high risk): CAC not needed, statin already indicated 1

Step 2: Verify patient is asymptomatic

• Any chest pain, dyspnea, or cardiac symptoms: CAC inappropriate, will be denied 1, 3
• Truly asymptomatic: proceed to Step 3 1

Step 3: Confirm age appropriateness

• Men <40 or women <50: CAC not indicated due to low calcification prevalence 1
• Age 40-75: appropriate age range 1, 2

Step 4: Document specific clinical uncertainty

• Patient reluctant to start statin due to side effect concerns 1
• Presence of risk-enhancing factors (family history of premature CAD, metabolic syndrome, chronic inflammatory disease, elevated Lp(a)) 1, 2
• Shared decision-making discussion documented where CAC result would change management 2

Step 5: Use appropriate ICD-10 codes

• Z13.6 (encounter for screening for cardiovascular disorders) for intermediate-risk screening 2
• Z82.49 (family history of ischemic heart disease) when applicable 2
• E78.5 (hyperlipidemia) when elevated cholesterol present 2

Critical Caveat About Cost Coverage

Not all insurance payors cover CAC scoring even when appropriately indicated, as it is considered a preventive screening test rather than diagnostic imaging. 1 Many patients must pay out-of-pocket (typically <$100), which should be discussed before ordering. 2 Medicare does not routinely cover CAC scoring for screening purposes. 1

What Happens When CAC is Inappropriately Ordered

When CAC is ordered outside guideline-supported indications:

• Insurance denies the claim, leaving the patient responsible for payment 1
• The test result may not change management (e.g., low-risk patient with CAC = 0 was already low-risk) 1
• Incidental findings (lung nodules found in 0.4-16.5% of scans) may trigger unnecessary follow-up testing and patient anxiety 1
• Radiation exposure (0.37-1.5 mSv) provides no clinical benefit when inappropriately used 2