Centers for Medicare and Medicaid Services (CMS) Medicare Administrative Contractors (MACS)
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Coverage Policies for Cardiac CT

Compiled June 23, 2017; updated November 13, 2017
Last Reviewed by SCCT: 1/20/2018

 

Noridian Healthcare Solutions, LLC

States Affected: Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Montana, Nevada, North Dakota, South Dakota, Utah, Washington, Wyoming

No current published policy.

 

Wisconsin Physicians Service Insurance Corporation – L35121

States Covered: Alaska, Alabama, Arkansas, Arizona, Connecticut, Florida, Georgia, Iowa, Idaho,
Illinois,
Indiana,
Kansas, Kentucky, Louisiana, Massachusetts, Maine,
Michigan, Minnesota, Missouri - Entire State, Mississippi, Montana, North Carolina, North Dakota, Nebraska,
New Hampshire, New Jersey, Ohio, Oregon,
Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Virginia, Virgin Islands, Vermont, Washington, Wisconsin, West Virginia, Wyoming

CPT Codes Covered: (CPT 75574,75573,75572) No CT FFR coverage

Indications:

Alternative to invasive angiography and stress testing:


For patients with anginal symptoms,

  • patients with unclear stress tests results
  • patients in whom the stress test result contradicts the clinical assessment
  • to determine the patency of coronary artery bypass grafts
  • alternative when cardiac catheterization is impossible or carries a high risk
  • to rule out stenosis before non-coronary cardiac surgery such as valve replacement or resection of tumors
  • clarifying unclear finding after invasive angiography.

 

Patient suspected of having a congenital coronary anomaly of great vessels, cardiac chambers and valves.

  • It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram.
  • CCTA is used to decide if surgery is indicated and for surgical planning.



Evaluate acute chest pain in the emergency department (ED)

  • The rationale is to quickly triage patients in order to rule out coronary artery disease as a possible cause of symptoms. Many will present with a normal electrocardiogram and myocardial enzymes.


Assess coronary or pulmonary venous anatomy.

  • Coronary mapping is primarily for pre-surgical planning such as pacemaker lead placement in the lateral coronary vein to resynchronize cardiac contraction in patients with heart failure, or guiding biventricular pacemaker placement
  • Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein mapping is primarily for catheter ablation which can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation, or help eliminate procedural complications.


Assess etiology with new onset heart failure for evaluation of coronary arteries


Limitations:

  • The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. 

  • The test will be considered not medically necessary if the anticipated results are not expected to provide 
new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing. 

  • The test will be considered not medically necessary if pretest evaluation indicates that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention. 

  • The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.) 

  • Coverage is limited to devices that process thin, high resolution slices (1mm or less). The multi-detector scanners must have at least 64 slices per rotation capability. 

  • The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable service. 

  • All studies must be ordered by the physician/qualified non-physician practitioner treating the patient and who will use the results of the test in the management of the patient. 

  • The test must be performed under the direct supervision of a physician, similar to the stress myocardial perfusion imaging. 

  • This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery examination. There is no extension of coverage of EBT based on this policy. 

  • Quantitative calcium scoring is not a covered service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring. 

  • Atrial fibrillation or atrial flutter alone is not an indication; atrial fibrillation or atrial flutter with planned ablation therapy is allowed. 


 

National Government Services, Inc. – L33559

States Covered: Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York (Entire state, Downstate, Upstate, Queens), Rhode Island, Vermont, Wisconsin.

CPT Codes Covered: (CPT 75574,75573,75572) No CT FFR coverage

Indications:

Patient presenting with chest pain syndrome:

  • CCTA may be used in lieu of an imaging stress test. The clinician must have a high degree of suspicion that CAD is high on the differential diagnosis of the symptoms.

To facilitate the management decision of a patient with an equivocal stress test.

  • CCTA might be chosen in select patients who have an equivocal stress (or stress imaging) test.

Recurrence of symptoms in patients with known coronary artery disease may be related to progression/exacerbation of underlying disease.

  • The use of CCTA in this setting would be to evaluate the extent of previously diagnosed coronary artery disease. Patients with known disease may have had remote invasive angiography and/or stress testing to evaluate prior events or symptoms. New or recurrent symptoms may relate to a change in the coronary anatomy that can be assessed with CCTA.

Patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or dyspnea:

  • Coronary bypass grafts are relatively well seen with CCTA. The rationale for CCTA would be to determine the patency and severity of possible graft stenosis that may be the source of chest pain.
  • Patients with prior intracoronary stents often present with recurrent chest pain. The rationale for a CCTA as an alternative to invasive angiography is to rule out in-stent restenosis as the cause of symptoms. (Accurate assessment of in-stent restenosis may be limited by the artifact caused by the stent material itself and the quality of the scan and scanner).

Suspected congenital anomalies of the coronary circulation.

  • CCTA is used to assess patients suspected of having a congenital coronary anomaly. The cross-sectional nature of this technique allows one to determine accurately both the presence and possible future harm that could result from the anomaly.
  • It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram. A CCTA is used to decide if surgery is indicated and for surgical planning.

The assessment of coronary or pulmonary venous anatomy.

  • This application of CTA for the coronary and pulmonary veins is primarily for pre-surgical planning.
  • Coronary venous anatomy can be useful for the cardiologist who needs to place a pacemaker lead in the lateral coronary vein in order to resynchronize cardiac contraction in patients with heart failure. This may be helpful to guide biventricular pacemaker placement.
  • Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein catheter ablation can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation. The presence of a pulmonary venous anatomic map may help eliminate procedural complications and allow for the successful completion of the procedure.

The patient undergoing non-coronary artery cardiac surgery.

  • Certain patients who have non-coronary artery cardiac surgery (valve or ascending aortic surgery) may need a pre-operative invasive coronary angiogram.
  • The surgical planning may also depend upon the exact location of the coronary arteries. The rationale for the use of CCTA in these patient subsets is to avoid potentially unnecessary invasive testing and still provide appropriate pre-surgical information.

Patients presenting to the emergency room with complaints consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes.

May be considered medically necessary in patients status post revascularization procedures who present with recurrent symptoms not clearly identifiable as ischemic.

Limitations:

  1. The test is never covered for screening, i.e., in the absence of signs, symptoms or disease. 

  2. The test will be considered not medically necessary if the anticipated results are not expected to provide 
new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing. 

  3. For dates of service prior to 01/01/2010, determination of cardiac ejection fraction (CPT code 0151T) should not be billed when previously determined by other techniques. CPT code 0151T is deleted effective 12/31/2009. 

  4. The test will be considered not medically necessary if it is anticipated that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.) 

  5. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value. 

  6. Effective 12/01/2009, coverage for evaluation of coronary artery or bypass graft stenosis, or for functional status (e.g., wall motion), is limited to multidetector scanners having at least 64 slices per rotation capability. This two year period (12/01/2007 - 12/01/2009 will allow for a phase-in of new technology. 

  7. The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable service. 
  8. All studies must be ordered by the physician/qualified non-physician practitioner treating the patient and who will use the results of the test in the management of the patient. 

  9. The test must be performed under the direct supervision of a physician. 

  10. This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery 
examination. There is no extension of coverage of EBT based on this policy. 

  11. Quantitative calcium scoring (CPT code 0144T for dates of service prior to 01/01/2010, and CPT 75571 on 
or after 01/01/2010) is not a covered service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring. 

  12. Acceptable Levels of Competence for Performance and Interpretation: Providers submitting claims for these tests must demonstrate proficiency and training in performing the tests.


 

Novitas Solutions, Inc.

States Affected: Arkansas, Colorado, Delaware, District of Columbia, Louisiana, Maryland, Mississippi, New Jersey, New Mexico, Oklahoma, Pennsylvania, Texas.

No current published policy.

 

First Coast Service Options, Inc. – L33282

States Covered: Florida, Puerto Rico, Virgin Islands

CPT Codes Covered: (CPT 75574,75573,75572) No CT FFR coverage

 
Indications:

MDCT angiography of the chest for non-cardiac assessment ( CPT 71275) will be considered medically reasonable and necessary for the following signs or symptoms of disease:

  • Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;
  • Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio-venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart;
  • Assessment of suspected congenital anomalies of the heart or great vessels; and
  • Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.

MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary for the following signs or symptoms of disease (CPT 75574,75573,75572).

  • Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid performing diagnostic cardiac catheterization.
  • Assessment of suspected congenital anomalies of coronary circulation.
  • Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging, if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary angiography would be done in addition to a subsequent coronary catheterization and angiogram).
  • Evaluation of pulmonary veins prior to arrhythmia ablation procedures.
  • Evaluation of cardiac veins prior to insertion of biventricular pacemaker.

Additionally, at times, it may be necessary to evaluate the patient for both cardiac and noncardiac disease.

Pending the assignment of a code that more precisely describes this service, protocols using cardiovascular CT angiography for the evaluation of acute chest pain in the emergency setting, where pulmonary and/or aortic vascular etiology are also a concern, must be coded with CPT code 71275 only.

Billing CPT code 71275 plus one of the following CPT codes (75571, 75572, 75573 or 75574) would attest to the fact that two completely separate procedures were performed in their entirety.

Limitations:

  • The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
  • The test is never covered for patients with stable coronary artery disease without any significant change in signs or symptoms.
  • The selection of the test should be made within the context of other testing modalities so that the resulting information facilitates the management decision, and does not merely add an additional layer of testing. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive calcification that would diminish the interpretive value.
  • Coverage of this modality for coronary artery assessment is limited to devices that process thin, high-resolution slices (0.75 mm or less) . A multidetector scanner must have a row of at least 32 detectors. For non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less.
  • The administration of beta-blockers and/or other medications and the monitoring of the patient by a physician during the MDCT are not separately payable services.
  • All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or qualified non-physician provider must be present during testing whenever cardioactive agents or contrast agents are administered (direct physician supervision). Ideally, this supervising physician will be experienced in this procedure and ACLS-certified.
  • Electron Beam Technology provides high temporal resolution and enables quantitative assessment of the coronary artery calcium, but because of limited spatial resolution as a result of the limited z axis resolution (slice thickness=3.0 mm), it does not permit direct visualization in multi-reformation of the whole coronary system. Therefore, CT angiography of the heart is not considered medically necessary when performed with an EBT scanner.
    ___________________________________________________________________
    Cahaba Government Benefit Administrators, LLC
    (will be going away soon. Lost Medicare contract).
    No published policy.
    ___________________________________________________________________
    Palmetto GBA, LLC –L33423 (Part B)
    States Covered:
    Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia, West Virginia.
    CPT Codes Covered: (CPT 75574,75573,75572, 0501T, 0502T, 0503T, 0504T)
    To establish CCTA medical necessity, your case must meet at least one indication in the following two categories:

    1. Symptomatic Coronary Artery Disease (CAD)

    Evaluation of Acute Chest Pain, unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw pain) when there is:
    • Intermediate pre-test probability of CAD*, and
    • No EKG changes to suggest acute myocardial injury or ischemia, and
    • Normal initial cardiac markers.
    • Patients with intermediate risk and a discordant clinical situation (e.g. ongoing ischemic symptoms, normal stress test).

    Evaluation of Chest Pain Syndrome, when there is:
    • Intermediate pre-test probability of CAD*, and
    • Uninterpretable EKG** or patient is unable to exercise, or
    • Uninterpretable or equivocal stress test (exercise, perfusion or stress echo)
    ** Uninterpretable EKG refers to EKGs with resting ST segment depression greater than or equal to 0.10mV, complete left bundle branch block, pre-excitation, or paced rhythm.


    Evaluation of intracardiac structures for suspected coronary anomalies.


    2. Suspected Cardiac Structural/Morphologic Anomalies

    Detection of intracardiac and extracardiac structures in:
    • Evaluation of cardiac mass (suspected tumor or thrombus) or
    • Evaluation of pericardial conditions (mass, constrictive pericarditis, or complications of cardiac surgery), or
    • Patients with technically limited images from echocardiogram, MRI or TEE.

    Detection of morphologic intracardiac and extracardiac structures for:
    • Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation. While data is limited for 3D reconstruction of the left atrium for ablations, there is broad consensus among cardiologists that these images, which are integrated and used in real-time in the procedure room to shorten procedure time, improve therapeutic success and enhance patient safety, or
    • Non-invasive coronary vein mapping prior to placement of biventricular pacemaker, or
    • Non-invasive coronary arterial mapping, including internal mammary artery, prior to repeat cardiac surgical revascularization, or
    • Detection of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chamber and valves, or
    • Evaluation of coronary arteries in patients with new onset heart failure to assess etiology.

    Limitations:

    1. Coverage of CCTA is limited to CT devices that process thin, high resolution slices. Decreased resolution and slower rotation speeds result in a higher number of non-evaluable segments. At the current time, Medicare requires the multidetector scanner to have collimation of 0.625 mm or less, and a rotational speed of 375 msec or less, OR to have at least 64 slice detector design. Do not submit studies from scanners that do not meet these requirements.

    2. Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for quantitative evaluation of coronary calcium. This LCD does not address Heartflow determinations.

    Ultrafast CT scan of the heart (electron-beam tomography [EBT] or electron-beam computed tomography [EBCT]) is not a covered service.

    3. Simultaneous exclusion of obstructive CAD, pulmonary embolism, and aortic dissection (“triple rule-out”) in the emergency department is not covered. In order to optimize imaging of the right coronary artery (RCA), contrast must be cleared from the right sided chambers during acquisition, a process that leads to suboptimal contrast timing in the pulmonary arteries. Simultaneous rule-out of aortic pathology (at the low pitch needed to properly image the coronaries) mandates thicker slices in order to capture the total volume required in a reasonable breath hold. The increased slice thickness degrades coronary image quality.

    4. CCTA patients must be able to lie still, follow breathing instructions, and take nitroglycerin for coronary dilatation.

    5. Prior to the initiation of a CCTA, the physician must make an assessment of the anatomic location, degree and intensity of calcification and impact of the calcification on the utility of the test results. CCTA’s performed on patients with elevated quantitative calcium scores that preclude accurate assessment of coronary anatomy are not covered by Medicare.
    ___________________________________________________________________
    CGS Administrators, LLC – L33947
    States Covered:
    Kentucky, Ohio
    CPT Codes Covered: (CPT 75574,75573,75572)

    Indications:
    Patient presenting with chest pain syndrome.
    • CCTA may be used in lieu of an imaging stress test. The clinician must have a high degree of suspicion that CAD is high on the differential diagnosis of the symptoms.
    To facilitate the management decision of a patient with an equivocal stress test.
    • CCTA might be chosen in select patients who have an equivocal stress (or stress imaging) test.
    When the recurrence of symptoms in patients with known coronary artery disease may be related to progression/exacerbation of underlying disease.
    • The use of CCTA in this setting would be to evaluate the extent of previously diagnosed coronary artery disease. Patients with known disease may have had remote invasive angiography and/or stress testing to evaluate prior events or symptoms. New or recurrent symptoms may relate to a change in the coronary anatomy that can be assessed with CCTA.

    When patients with prior bypass surgery or intracoronary artery stent placement present with chest pain or dyspnea.
    • Coronary bypass grafts are relatively well seen with CCTA. The rationale for CCTA would be to determine the patency and severity of possible graft stenoses that may be the source of chest pain.
    • Patients with prior intracoronary stents often present with recurrent chest pain. The rationale for a CCTA as an alternative to invasive angiography is to rule out in-stent restenosis as the cause of symptoms. (Accurate assessment of in-stent restenosis may be limited by the artifact caused by the stent material itself and the quality of the scan and scanner).

    Suspected congenital anomalies of the coronary circulation.
    • CCTA is used to assess patients suspected of having a congenital coronary anomaly. The cross-sectional nature of this technique allows one to determine accurately both the presence and possible future harm that could result from the anomaly.
    • It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram. A CCTA is used to decide if surgery is indicated and for surgical planning.

    The assessment of coronary or pulmonary venous anatomy.
    • This application of CTA for the coronary and pulmonary veins is primarily for pre-surgical planning. Coronary venous anatomy can be useful for the cardiologist who needs to place a pacemaker lead in the lateral coronary vein in order to resynchronize cardiac contraction in patients with heart failure. This may be helpful to guide biventricular pacemaker placement.
    • Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein catheter ablation can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation. The presence of a pulmonary venous anatomic map may help eliminate procedural complications and allow for the successful completion of the procedure.

    The patient undergoing non-coronary artery cardiac surgery.


• Certain patients who have non-coronary artery cardiac surgery (valve or ascending aortic surgery) may need a pre-operative invasive coronary angiogram. The surgical planning may also depend upon the exact location of the coronary arteries.
• The rationale for the use of CCTA in these patient subsets is to avoid potentially unnecessary invasive testing and still provide appropriate pre-surgical information.

The test may be medically necessary in patients presenting to the emergency room with complaints consistent with cardiac ischemia, but without diagnostic electrocardiography (ECG) or enzymes.

The test may be considered medically necessary in patients status post revascularization procedures who present with recurrent symptoms not clearly identifiable as ischemic.

Limitations:

a. The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
b. The test will be considered not medically necessary if the anticipated results are not expected to provide new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing.
c. For dates of service prior to 01/01/2010, determination of cardiac ejection fraction (CPT code 0151T) should not be billed when previously determined by other techniques. CPT code 0151T is deleted effective 12/31/2009.
d. The test will be considered not medically necessary if it is anticipated that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.)
e. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value.
f. Effective 12/01/2009, coverage for evaluation of coronary artery or bypass graft stenosis, or for functional status (e.g., wall motion), is limited to multidetector scanners having at least 64 slices per rotation capability. This two year period (12/01/2007 - 12/01/2009 will allow for a phase-in of new technology.
g. The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable service.
h. All studies must be ordered by the physician/qualified non-physician practitioner treating the patient and who will use the results of the test in the management of the patient.
i. The test must be performed under the direct supervision of a physician.
j. This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery examination. There is no extension of coverage of EBT based on this policy.
k. Quantitative calcium scoring (CPT code 0144T for dates of service prior to 01/01/2010, and CPT 75571 on or after 01/01/2010) is not a covered service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring.
l. Acceptable Levels of Competence for Performance and Interpretation: Providers submitting claims for these tests must demonstrate proficiency and training in performing the tests.

703-766-1706
800-876-4195

415 Church St. NE, Suite 204
Vienna, VA 22180-4751