United Healthcare Revises Cardiac Computed Tomography (CT), Coronary Artery Calcium Scoring and Cardiac CT Angiography Policy

Changes to Coverage:

Coronary artery calcium scoring using electron beam or multi-slice computed tomography 16-slice or greater technology, is proven for the following:

• risk stratification in asymptomatic patients with moderate risk for coronary heart disease (CHD) based on Framingham score
• as a triage tool for symptomatic patients to rule out obstructive disease and avoid an invasive procedure Coronary artery calcium scoring is unproven for all other indications, including routine screening. The evidence indicates that screening asymptomatic adults for coronary heart disease is ineffective and that the harms may outweigh the benefits.

Cardiac CT angiography

Computed tomography angiography (CTA), using 32-slice or greater technology, is proven for assessing the following:

• detecting coronary artery disease in asymptomatic patients with high risk of coronary heart disease (CHD)¹
• to rule out coronary artery disease in symptomatic patients with a low to intermediate pre-test probability of coronary artery disease (CAD)2
• chest pain syndrome following a revascularization procedure (stent placement or angioplasty)
• suspected coronary artery anomaly
• preoperative risk assessment for intermediate or high risk non-cardiac surgery³
• morphology of congenital heart disease, including anomalies of coronary circulation, great vessels and cardiac chambers and valves
• assessment of coronary arteries in patients with new onset heart failure to assess etiology

Computed tomography angiography (CTA) is unproven for the following:

• detecting coronary artery disease in symptomatic patients with a high pre-test probability of CAD²
• assessing coronary arteries in symptomatic patients with previously diagnosed CAD
• post-revascularization procedure to rule out in-stent restenosis or assess bypass grafts in asymptomatic patients
• routine screening in asymptomatic patients or patients at low risk of CAD

Although CTA may be a possibility to rule out in-stent restenosis, routine application of CT to assess patients with coronary stents can currently not be recommended. Visualization of the stent lumen is often affected by artifacts, and especially the positive predictive value is low.

Although CTA may be useful in carefully selected patients with bypass grafts, the inability to reliably visualize the native coronary arteries in patients post-CABG poses severe restrictions to the general use of CT angiography in post-bypass patients.

Coronary CTA should only be considered when the potential risks posed by catheterization outweigh the potential risks posed by the somewhat less accurate detection of clinically significant CAD by CTA. In addition, coronary CTA is not suitable for patients who are likely to require coronary angioplasty or stenting since CTA will not allow these patients to avoid cardiac catheterization in any event, and this is the primary advantage of coronary CTA.

Cardiac CT

Cardiac computed tomography, with or without contrast, using 32-slice or greater technology, is proven for assessing cardiac structure/anatomy for the following:

• pulmonary vein anatomy prior to ablation procedure
• coronary vein mapping prior to placement of biventricular pacemaker or biventricular implantable cardioverter defibrillator
• coronary arterial mapping, including internal mammary artery, prior to repeat sternotomy
• suspected cardiac mass (tumor or thrombus) or pericardial disease in patients with technically limited images from echocardiogram, magnetic resonance imaging (MRI) or transesophageal echocardiogram (TEE)

Additional information - Accreditation

Compliance with this policy will become a condition for reimbursement from UnitedHealthcare in the fourth quarter of 2009. No official date has been set, but we will keep you updates as this becomes available. For more information on the accreditation requirements, please click here.