This website uses cookies to store information on your computer. Some of these cookies are used for visitor analysis, others are essential to making our site function properly and improve the user experience. By using this site, you consent to the placement of these cookies. Click Accept to consent and dismiss this message or Deny to leave this website. Read our Privacy Statement for more.
AIM Coverage Policy
Share |

AIM Coverage Policies

Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification

CPT Codes

 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium
  • This guideline pertains to cardiac CT for quantitative evaluation of coronary artery calcification using either Electron Beam CT (EBCT) or Multi-Detector CT (MDCT).
  • This guideline does not apply to coronary CT angiography (CPT 75574).
  • This guideline does not apply to cardiac CT for evaluation of cardiac structure and function (CPT 75572-75573).

Quantitative Evaluation of Coronary Artery Calcification

considered to be not medically necessary in all clinical situations

Computed Tomography (CT) Cardiac (Structure)
CPT Codes
 75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3-D image post-processing, assessment of cardiac function, and evaluation of venous structures if performed) 
 75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3-D image post-processing, assessment of cardiac function, and evaluation of venous structures if performed) 
  • This guideline does not apply to coronary CT angiography (CPT 75574).
  • This guideline does not apply to Cardiac CT for quantitation of coronary artery calcification (CPT 75571).
  • Selection of the optimal diagnostic work-up for cardiac evaluation should be made within the context of other available studies (which include transthoracic and transesophageal echocardiography and cardiac MRI), so that the resulting information facilitates patient management decisions and does not merely add a new layer of testing.
  • There are uncommon circumstances when both Cardiac CT and Cardiac MRI should be ordered for the same clinical presentation. The specific rationale must be delineated at the time of request.
  • In general, follow-up Cardiac CT exams should be performed only when there is a clinical change, with new signs or symptoms, or specific finding(s) requiring imaging surveillance.

Common Diagnostic Indications

Congenital heart disease:

  • For evaluation of suspected or established congenital heart disease in patients whose echocardiogram is technically limited or non-diagnostic; OR
  • For further evaluation of patients whose echocardiogram suggests a new diagnosis of complex congenital heart disease; OR
  • For evaluation of complex congenital heart disease in patients who are less than one year post surgical correction; OR
  • For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a change in physical examination; OR
  • To assist in surgical planning for patients with complex congenital heart disease; OR
  • For surveillance in asymptomatic patients with complex congenital heart disease who have not had cardiac MRI or cardiac CT within the preceding year
    • Cardiac MRI or transesophageal echocardiography may be preferable to cardiac CT in order to avoid radiation exposure

Cardiomyopathy:

  • Evaluation of patients with suspected arrhythmogenic right ventricular dysplasia; OR
  • To assess LV function in patients with suspected or established cardiomyopathy when all other non-invasive imaging is not feasible or technically suboptimal
    • Other modalities providing non-invasive evaluation of LV function include transthoracic and transesophageal echocardiography, blood pool imaging (MUGA or First pass) and cardiac MRI; OR
  • To assess RV function in patients with suspected RV dysfunction when all other non-invasive imaging is not feasible or technically suboptimal
    • Other modalities providing non-invasive evaluation of RV function include transthoracic and transesophageal echocardiography, blood pool imaging (MUGA or First pass) and cardiac MRI

Valvular heart disease:

  • Evaluation of suspected dysfunction of native or prosthetic cardiac valves when all other cardiac imaging options are not feasible or technically suboptimal
    • Other modalities providing non-invasive evaluation of native or prosthetic valves include transthoracic and transesophageal echocardiography, and cardiac MRI
  • Evaluation of established dysfunction of native or prosthetic cardiac valves when all other cardiac imaging options are not feasible or technically suboptimal
    • Other modalities providing non-invasive evaluation of native or prosthetic valves include transthoracic and transesophageal echocardiography, and cardiac MRI

Evaluation of patients with established coronary artery disease:

  • Non-invasive localization of coronary bypass grafts or potential grafts (including internal mammary artery) and/or evaluation of retrosternal anatomy in patients undergoing repeat surgical revascularization

Intra-cardiac and para-cardiac masses and tumors:

  • In patients with a suspected cardiac or para-cardiac mass (thrombus, tumor, etc.) suggested by transthoracic echocardiography, transesophageal echocardiography, blood pool imaging or contrast ventriculography who have not undergone cardiac CT or cardiac MRI within the preceding 60 days; OR
  • In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable; OR
  • In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically stable and have not undergone cardiac CT or cardiac MRI within the preceding year; OR
  • In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who have undergone treatment (chemotherapy, radiation therapy, thrombolysis, anticoagulation or surgery) within the preceding year and have not had cardiac CT or cardiac MRI within the preceding 60 days

Common Diagnostic Indications

Cardiac aneurysm and pseudoaneurysm

Evaluation of pericardial conditions (pericardial effusion, constrictive pericarditis, or congenital pericardial diseases):

  • In patients with suspected pericardial constriction; OR
  • In patients with suspected congenital pericardial disease; OR
  • In patients with suspected pericardial effusion who have undergone echocardiography deemed to be technically suboptimal in evaluation of the effusion; OR
  • In patients whose echocardiogram shows a complex pericardial effusion (loculated, containing solid material)

Evaluation of cardiac venous anatomy:

  • For localization of the pulmonary veins in patients with chronic or paroxysmal atrial fibrillation/flutter who are being considered for ablation; OR
  • Coronary venous localization prior to implantation of a biventricular pacemaker

Evaluation of the thoracic aorta:

  • In patients with suspected thoracic aortic aneurysm / dilation who have not undergone CT or MRI of the thoracic aorta within the preceding 60 days; OR
  • In patients with confirmed thoracic aortic aneurysm / dilation with new or worsening signs/symptoms; OR
  • For ongoing surveillance of stable patients with confirmed thoracic aortic aneurysm / dilation who have not undergone surgical repair and have not had imaging of the thoracic aorta within the preceding six months; OR
  • In patients with suspected aortic dissection; OR
  • In patients with confirmed aortic dissection who have new or worsening symptoms; OR
  • In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative planning); OR
  • For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of the thoracic aorta within the preceding year; OR
  • In patients with confirmed aortic dissection or thoracic aortic aneurysm / dilation who have undergone surgical repair within the preceding year and have not undergone imaging of the thoracic aorta within the preceding six months; OR
  • In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of aortic instrumentation; OR
  • In patients being evaluated for potential transcatheter aortic valve implantation/replacement (TAVI or TAVR) provided that the patient has not undergone cardiac CT or cardiac MRI within the preceding 60 days
Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT)

CPT Codes

 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (where present), with contrast material, including 3-D image post-processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
 0501T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report 
 0502T Data preparation and transmission 
 0503T Analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model 
 0504T Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report 

Note: Codes 0501T–0504T are effective January 1, 2018. These codes should be reported if FFR is estimated from CCTA data.

Scope of this Guideline

The guideline addresses the appropriate application of CCTA and FFR-CT in the evaluation and management of outpatients.

It does not address the use of CCTA and FFR-CT in the emergency room or inpatient settings.

Guideline Interpretation

This guideline does not supersede the enrollee’s health plan medical policy specific to CCTA and FFR-CT.

Common Diagnostic Indications

The use of CT Coronary Angiography (CCTA), with or without Fractional Flow Reserve assessed by CT (FFR-CT), may be covered when accompanied by pre-test considerations as well as supporting clinical data and prerequisite information based on the following diagnostic indications.

For purposes of this guideline, a patient is considered to be “symptomatic” when one of the following (1–4) applies:

1. Chest pain

  • With intermediate or high pretest probability of CAD; OR
  • With low or very low pretest probability of CAD and high risk of CAD (SCORE)

2. Atypical symptoms: shortness of breath (dyspnea), neck, jaw, arm, epigastric or back pain, sweating (diaphoresis), or exercise-induced syncope

  • With moderate or high risk of CAD (SCORE)

3. Other symptoms: palpitation, nausea, vomiting, anxiety, weakness, fatigue, or exercise-induced dizziness, lightheadedness or near syncope, etc.

  • With high risk of CAD (SCORE)

4. Patients with any cardiac symptom who have diseases/conditions with which CAD commonly coexists, such as:

  • Abdominal aortic aneurysm; OR
  • Chronic renal insufficiency or renal failure; OR
  • Diabetes mellitus; OR
  • Established and symptomatic peripheral vascular disease; OR
  • Prior history of cerebrovascular accident (CVA), transient ischemic attack (TIA) or carotid endarterectomy (CEA) or high grade carotid stenosis (>70%)

Indications where FFR-CT will not be required in conjunction with CCTA

Congenital coronary artery anomalies:

  • For evaluation of suspected congenital anomalies of the coronary arteries

Indications where FFR-CT may be appropriate but is not a required capability of the performing imaging facility

Congestive heart failure/cardiomyopathy/left ventricular dysfunction:

  • For exclusion of CAD in patients with left ventricular ejection fraction <55% and low to moderate coronary heart disease risk (using standard methods of risk assessment, such as the SCORE risk calculation) in whom CAD has not been excluded as the etiology of the cardiomyopathy
    • Patients with high coronary heart disease risk should undergo cardiac catheterization

Preoperative evaluation for patients undergoing non-coronary cardiac surgery:

  • Evaluation of symptomatic or asymptomatic patients at moderate coronary heart disease risk (using standard methods of risk assessment, such as the SCORE risk calculation) to avoid an invasive angiogram, where all the necessary preoperative information can be obtained using cardiac CT
    • Procedures include open and percutaneous valvular procedures or ascending aortic surgery

Suspected coronary artery disease in patients who have had abnormal exercise EKG test (performed without imaging) within the past 60 days:

  • When both of the following apply:
    • Patient is symptomatic
    • During testing the patient had exercise-induced chest pain, ST segment change, abnormal BP response or complex ventricular arrhythmias

Common Diagnostic Indications

Suspected coronary artery disease in patients who have had equivocal MPI or SE within the past 60 days:

  • When both of the following apply:
    • Patient is symptomatic
    • The imaging portion of the study is neither clearly normal nor clearly abnormal

Suspected coronary artery disease in patients who have had abnormal MPI or SE within the past 60 days:

  • When both of the following apply:
    • Patient is symptomatic
    • The imaging portion of the study is abnormal

Indications where FFR-CT may be appropriate and is a required capability of the imaging facility

Suspected coronary artery disease in symptomatic patients who have abnormal resting EKG:

  • When resting EKG abnormalities (left bundle branch block, electronically paced ventricular rhythm, left ventricular hypertrophy with repolarization abnormalities, resting ST segment depression 1 mm or more, digoxin effect or preexcitation syndrome) would render an exercise treadmill test (without imaging) uninterpretable

Suspected coronary artery disease in symptomatic patients who have not had recent CAD evaluation:

  • When no CAD imaging evaluation (MPI, cardiac PET, stress echo, CCTA or coronary angiography) has been performed within the preceding sixty (60) days
Copyright © 2019. AIM Specialty Health. All Rights Reserved.
 
703-766-1706

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