Heartening News For The New Year! United Health Care Paid For This Patient’s Coronary Calcium Scan

Unless you live in Texas you will have to pay out of pocket for a coronary artery calcium (CAC) scan. Insurers and Medicare won’t pay a dime for this simple test which  progressive preventive cardiologists and primary care docs rely on to better determine who is at risk for heart attacks and sudden death.

But as we approach 2020 perhaps this failure to cover our best tool to detect subclinical atherosclerosis can be reversed. To my surprise, earlier this week, a patient of mine revealed to me that United Health Care had reimbursed him for the CAC he had done earlier this year.

It wasn’t easy or straightforward but his process may work for others so I asked him to email me the letter he sent that resulted in coverage which I have copied below.

As discussed in your office today, I was able to get my insurance company (United Healthcare) to reimburse me from the Cardiac Calcium Scoring costs of $125 after filing an appeal through my former employer. Below, as requested, is the simple write up I provided to them.

I visited a cardiologist (Dr. Anthony Pearson) in May 2019 regarding heart palpitations I had with increasing frequency. He performed a variety of diagnostic tests (blood work, Holter monitor, echo stress test), which were all covered by UHC. Because these tests did not show any issues, he suggested I have a Cardiac Calcium Scoring Test, which I completed on May 24, 2019. The test showed that I had serious coronary artery disease (score of over 800), which caused the cardiologist to prescribe a daily baby aspirin and a statin medicine (also covered by UHC). While I was told that the Cardiac Calcium Scoring Test cost is not covered by insurance, this is the one and only test that indicated I was at a severe risk for a coronary artery event (significant or total blockage) and, per the cardiologist, may have saved my life or perhaps avoided an unexpected significant cost (e.g. bypass surgery) by catching the issue early.

To recap, St. Luke’s Hospital did not submit a claim for the $125 cost of the Cardiac Calcium Scoring Test because they said no insurance company pays for this test. This test was ordered by my cardiologist, Dr. Anthony Pearson, and was performed at St. Luke’s Hospital in St. Louis. I am requesting reimbursement for the cost of this test for the reasons stated above

The United Health Care EOB contained this claims summary:

Screen Shot 2019-12-31 at 9.34.20 AM

It would appear the mighty wall that insurers and CMS have put up against paying for CAC scans is crumbling and can be breached.

I highly recommend all patients who have gotten an appropriately ordered CAC go through this process with their insurers to attempt to obtain reimbursement.

Happy Antiatherosclerotic New Year,

-ACP

9 thoughts on “Heartening News For The New Year! United Health Care Paid For This Patient’s Coronary Calcium Scan”

  1. I don’t think the wall is crumbling concerning health insurance payments for CAC scores. These companies follow the recommendations of the USPSTF guidelines and recommendations. That being said, looking at a CAC score of healthy patients without symptoms and risk factors such as smoking, obesity, high cholesterol, diabetes lack of exercise, and hypertension does not make sense anyway in my opinion. You can manage the risk factors but not the CAC. In fact, I don’t know of any studies that suggest you can even reverse the CAC score. Do you know of any? So I guess i have rambled somewhat. I would conclude by asking what is the recommendation of the USPSTF concerning CAC exames?

    I enjoyed the write up!

    1. Erwin,
      Those who have a strong family history but no symptoms and no perceived risk factors stand to benefit most from CAC.
      The calcium in the arteries is a marker for subclinical atherosclerosis. It is a sign that plaque has built up and also a marker of healing/maturity of the plaques. The calcium itself is not the problem so we shouldn’t be interested in studies that reverse calcium but studies that show identification of advanced early plaque by CAC coupled with aggressive lifestyle changes and medical therapy reduce the consequences of the subclinical atherosclerosis-heart attack, sudden death and stroke.
      The USPSTF does not recommend CAC exams.

  2. ACP is a good writer. Good to see someone “work” the system. Here in CT the price is $100 & even in my inner city practice, the vast majority can afford that price. Moreover, the goal is nonHDL OF < 90, TG < 100, etc risk reduction would stop progress of any CAD & begin reversal if Rx vigorous enuf & then the Cor Ca++ would have been an unnecessary exposure to significant radiation. HRS, MD, FACC

  3. What did you think of John Mandrola’s article advising against CAC? It made little sense to me but I’d like to hear your opinion. Thanks.

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