Why doesnt insurance cover coronary calcium scan

CHARLOTTE, N.C. -- Tick tock, tick tock. In the next eighty seconds, two people in the United States will die of heart disease; on average it kills 2,200 Americans each day. I put my heart to the test -- a test that could save your life.

The test will show me the inside of my heart, specifically, what’s in my arteries. But first, why I’m doing this? Why do I think you should see it? Why should insurance companies consider paying for it?

“My father died of a sudden heart attack in his mid-40’s, and I witnessed it, and I saw what a man’s heart attack looks like. A woman’s heart attack doesn’t look like that” said Christine O’Boyle.

At the same stage of life as her dad, Christine, then in her mid-40’s, a woman who didn’t smoke, didn’t drink, ate well and exercised --had a heart attack too. It began during an afternoon walk, and the symptoms lingered.

“I had nausea, I was sweating, I had shoulder and back pain, and indigestion I had, that’s a big thing among women,” Christine said.

Christine’s husband recognized what was happening and insisted on going to the emergency room. He was right. Heart disease is the number one killer of both men and women, more than all cancers combined. In fact, it will kill one in three adults.

That brings me back to this test called the calcium scoring. At 51-years-old, it’ll show how much plaque I have in my arteries and help determine my risk of a heart attack or stroke.

This test is $150 and not covered by insurance. Why not? It’s preventative, just like mammograms, pap smears and colonoscopies.

By the numbers, it makes sense. The all in cost for a heart attack can be $750,000 or more. If insurance covered the $150 for the calcium scoring, it means 5,067 people could see and learn their risk and maybe avoid a deadly cardiac event.

My test took only 10 minutes at Novant. My result?

“There is a small fleck of calcium in one of your arteries in your heart so that gives a calcium score of not zero; it implies a certain amount of cardiovascular risk, but in this case, the risk is very normal for your age” said Dr. Erik Insko, MD, PhD who is the diagnostic radiology specialist at Novant.

I’m not 100% in the clear, but I now know. It’s well worth $150 and some piece of mind. If you are interested in learning your score, talk to your doctor.

Your blood work is in and, uh oh, your LDL cholesterol remains stubbornly elevated (or high). But your overall risk of heart disease is neither high nor low. You're in the middle, and you're on the fence about starting a statin. Now what?

A CT scan of your heart might provide the tiebreaking piece of information you and your doctor need to decide whether statin therapy is appropriate.

The scan can help differentiate patients at moderate risk for heart disease into higher or lower risk groups, explains Mary Norine Walsh, MD, past president of the American College of Cardiology (ACC) and medical director of heart failure and cardiac transplantation at St. Vincent Heart Center of Indiana in Indianapolis.

The ACC and American Heart Association (AHA) included the scan, called a coronary artery calcium (CAC) test, in cholesterol management guidelines published in November 2018. The results of this screening test can predict your risk of heart attack.

"That piece of information alone can't help prevent a heart attack or stroke," said Dr. Walsh. It's the action people take on those results that can make a difference.

But testing isn't universally endorsed. The U.S. Preventive Services Task Force (USPSTF) in July 2018 said current evidence is "insufficient" to weigh the benefits and harms of adding this test to traditional risk assessment measures for heart attack and stroke prevention in people without symptoms.

The test itself is quick and non-invasive. A CT (computed tomography) scan, a type of low-dose X-ray of your coronary arteries (the blood vessels that supply blood to the heart muscle), shows "calcified" or hardened plaque that may be present. Left untreated, these fat-and-calcium deposits can raise your risk for having a heart attack.

Based on scan results, you'll get a calcium score. Zero means there's no identifiable plaque. A score of 100 or more is a tipping point. It signals plaque is present, and statin therapy is generally recommended.

The scale itself has no upper end, says Ron Blankstein, MD, president-elect of the Society of Cardiovascular Computed Tomography and a preventive cardiology specialist at Brigham and Women's Hospital in Boston. He has some patients with scores well over 1,000.

Coronary calcium testing doesn't replace traditional risk assessment tools that factor in things like LDL, blood pressure, and smoking. Nearly half of all Americans have at least one of these risks, according to the Centers for Disease Control and Prevention. But the CAC test can help you and your healthcare provider decide whether to start a cholesterol-busting statin drug.

Statin drugs are recommended as a preventive therapy if your predicted risk of having a heart attack or stroke in the next 10 years exceeds certain thresholds based on data from population studies. And if your predicted risk is neither high nor low, it's a tough call. Why start a statin if your arteries are clean as a whistle?

That's why cardiologists favor a more personalized approach that incorporates individual "risk-enhancing" factors, including the use of coronary calcium scores when the statin/no statin decision isn't crystal clear.

LDL, or low-density lipoprotein, is the "bad" type of cholesterol considered a major risk for heart disease. An LDL of less than 70 is optimal for people at high risk for heart disease and, for everyone else, the goal is less than 100. An LDL of 190 or above is "very high."

Under the 2018 AHA/ACC guidelines, calcium scoring may be an option for adult patients ages 40 to 75 without diabetes if:

• LDL is 70 mg/dL or higher but risk of heart attack or stroke over the next 10 years is "uncertain."
• LDL is between 70 and 189 md/dL and 10-year heart disease risk is "intermediate," but a decision about starting therapy is uncertain.

"It's definitely something we want to use when our risk is kind of in the range where maybe we want to start a statin, maybe we don't," said Anthony Pearson, MD, a private practice cardiologist affiliated with St. Luke's Hospital, in Chesterfield, Mo.

If you're facing a statin/no statin decision, coronary calcium can help you and your doctor individualize treatment, cardiologists say.

Let's say your calcium score is zero. That suggests your heart disease risk is lower than predicted. You might be able to avoid or delay statin therapy, as long as you don't smoke, have diabetes, or have a family history of heart disease.

In fact, a 2018 retrospective study published in the Journal of the American College of Cardiology of more than 13,600 patients who were followed for almost 10 years found no clinical benefit of starting a statin in patients with a calcium score of zero.

But if you have a score of 100, this means "you're going to benefit a lot" from starting a statin, said Dr. Pearson.

Evidence of plaque could even kick-start changes in behavior. "For example, someone who's smoking may be more motivated to quit," added Dr. Walsh.

Every time you have a CT scan, you expose yourself to radiation. The dose is relatively low, according to the USPSTF. But it could be concerning if a patient requires repeated scans.

Being reclassified into a high-risk category could pose "psychological harms," noted the task force.

There's a risk that the results might provide false reassurance. A zero score doesn't get you off the hook from managing risk factors, for example.

Plus, there's a chance the scan will reveal "incidental findings," extra things that show up on the test, like a nodule on your lung. Depending on their nature, incidental findings may require follow-up scans and procedures.

Coronary calcium scoring is not for people at low risk of heart disease. That includes most young adults. If you're 20 to 39, the best thing you can do is embrace a heart-healthy lifestyle. Eat your greens, get up, and move—you know the drill. Doing these things can reduce risk factors that may lead to future heart disease.

The CAC test is also not for high-risk patients. For people in this group, the guidelines call for statin therapy and sometimes other preventive medicines, along with lifestyle improvements, to ward off heart woes.

Talk to your healthcare provider about your heart disease risk. You can also estimate it using an online calculator, such as ones offered by the ACC and the National Heart, Lung, and Blood Institute.

"Knowing your risk factors is the important first step," said Dr. Walsh.

If you decide to get tested, you'll likely pay out of pocket. The price tag? Typically $100 to $150, said Dr. Blankstein. But self-pay rates vary widely across the nation. (I called three testing sites in my neck of the woods and got quotes ranging from $300 to $500.)

As to why insurers in most states don't cover the test, Cathryn Donaldson, communications director at America's Health Insurance Plans, cited a lack of high-quality data from randomized controlled trials to demonstrate that it improves clinical outcomes and reduces the rate of cardiac "events" such as heart attacks.

Without large randomized trials to rely on, AHA/ACC turned to observational studies, which show that calcium scoring can help identify patients who may benefit from preventive treatment. (An observational study does just that, it observes people, their health, and their behaviors, while a randomized controlled trial is a true experiment in that it tests groups in different conditions and provides much stronger evidence than an observational study.)

However, you may be in luck if you live in Texas. As of June 2022, Texas is the only state with laws ensuring insurance coverage for these tests for eligible patients. In the late 2010s and early 2020s, there was much scientific interest in demonstrating the benefits of this test. If enough evidence is provided, more states may enact laws to have these tests covered by health insurance.

Ultimately, some cardiologists like Dr. Pearson hope insurers will have a change of heart once the scientific evidence is there to support the ability of this test to predict the risk of heart disease. Until then, keep managing your risk factors for heart disease and talk to your healthcare provider if you think this test would be beneficial to you.

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