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09.00.58b, Coronary Artery Calcium (CAC) Testing Using Computed Tomography (Independence Administrators)
Effective date
Sep 19, 2026
Identified
Sep 9, 2026
Summary
Independence Administrators updated CAC testing policy to clarify that coronary artery calcium testing is medically necessary if it has not been performed within the preceding 5 years in eligible low-risk individuals. The policy effective 09/19/2026 specifies strict clinical criteria for coverage, including age 40-75, LDL 70-190 mg/dL, 10-year ASCVD risk 5-20%, and absence of multiple exclusionary conditions. All other uses remain experimental/investigational and non-covered.
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What to do
Action · 7 steps
01By 09/19/2026: Billing team must update authorization protocols and claim submission procedures to enforce the 5-year interval requirement for CAC testing (CPT 75571).
02Implement verification step in billing system to confirm no prior CAC test within preceding 5 years before claim submission.
03Providers and clinical staff must document all required medical necessity criteria on encounter forms: age 40-75, LDL cholesterol 70-190 mg/dL, ASCVD 10-year risk score 5-20%, and confirmation of absence of ALL exclusionary conditions (family history of premature ASCVD, elevated lipids/triglycerides, metabolic syndrome, CKD, inflammatory conditions, early menopause, preeclampsia, high-risk race/ethnicity, and ASCVD risk markers).
04Update denial reason codes for claims lacking proper documentation or failing to meet criteria.
05Front desk and scheduling staff should note on encounter forms that diagnostic coding must include one of the approved ICD-10 codes (E78.00, E78.010, E78.011, E78.019).
06Claims submitted without documented medical necessity criteria or for patients with prior CAC within 5 years will be denied.
07This applies only to Independence Administrators members whose groups have NOT enrolled in Carelon Medical Benefits Management.
Codes mentioned
75571E78.00E78.010E78.011E78.019
Original notice
09.00.58b, Coronary Artery Calcium (CAC) Testing Using Computed Tomography (Independence Administrators)
medpolicy.ibx.com · Always check the source before changing claims.
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