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AIM Coverage Policy
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AIM Coverage Policies

Effective November 2019

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

CPT Codes

The following codes may be applicable to cardiac imaging and may not be all-inclusive. Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary artery calcium

GENERAL INFORMATION

Standard Anatomic Coverage

● Coronary artery imaging

IMAGING CONSIDERATIONS

Advantages of cardiac CT for quantitative evaluation of coronary artery calcification:

● Rapidly acquired exams

● Coronary artery calcification has been shown to correlate with the presence of atheromatous coronary artery disease

Disadvantages of cardiac CT for quantitative evaluation of coronary artery calcification:

● Exposure to ionizing radiation

● No role in the evaluation of patients with symptoms potentially due to coronary artery disease

● Not clear that risk stratification data provided by quantitative evaluation of coronary artery calcification impacts patient outcomes

Biosafety issues:

● Ordering and imaging providers are responsible for considering safety issues prior to performing quantitative evaluation of coronary artery calcification.

Ordering issues:

● Cardiac CT for quantitative evaluation of coronary artery calcification is not covered by most healthcare insurers as a screening study.

● Selection of the optimal diagnostic work-up for cardiac evaluation should be made within the context of other available studies (which include treadmill stress test, stress myocardial perfusion imaging, stress echocardiography, cardiac MRI, cardiac PET imaging, and invasive cardiac/coronary angiography), so that the resulting information facilitates patient management decisions and does not merely add a new layer of testing.

● 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 and 75573).

 

CLINICAL INDICATIONS

Coronary artery calcium (CAC) testing is appropriate to assist with decisions regarding management of hypercholesterolemia when ALL of the following apply:

● No known atheromatous vascular disease

● Not diabetic

● Age ≥ 40 years and ≤ 75 years

● Low-density lipoprotein (LDL) cholesterol ≥ 70 mg/dL and ≤ 190 mg/dL

● 10-year risk (using pooled cohort equations) ≥ 5% and ≤ 20%

● The patient does not have ANY of the following:

o Family history of premature atherosclerotic cardiovascular disease

o Persistently elevated low-density lipoprotein (≥ 160 mg/dL)

o Persistently elevated triglyceride (> 175mg/dL)

o Metabolic syndrome

o Chronic kidney disease (eGFR 15-59 mL/min/1.73 m2)

o Chronic inflammatory condition

o History of menopause before age 40 years

o History of preeclampsia

o High risk race/ethnicity (e.g., South Asian ancestry)

o Markers associated with increased risk of atherosclerotic cardiovascular disease (if measured):

Elevated high-sensitivity C-reactive protein (≥ 2.0 mg/L)

Elevated lipoprotein(a) (> 50mg/dL)

Apolipoprotein B > 130mg/dL

Ankle-brachial index less than 0.9

 

 

Computed Tomography (CT) Cardiac Structure and Morphology
CPT Codes

The following codes may be applicable to cardiac imaging and may not be all-inclusive. Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

 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) 

GENERAL INFORMATION

Standard Anatomic Coverage

● Heart and great vessels within the thorax

Imaging Considerations

Advantages of cardiac CT

● Rapidly acquired exams, with excellent anatomic detail afforded by most multi-detector CT scanners with 64 or more active detector rows

Disadvantages of cardiac CT

● Potential complications from use of intravascular iodinated contrast administration (see biosafety issues, below)

● Exposure to ionizing radiation

● Potential factors that may limit the image quality during acquisition of cardiac CT such as:

o Uncontrolled atrial or ventricular arrhythmias

o Inability to image at a desired heart rate, which may occur despite beta blocker administration

o Inability of the patient to comply with the requirements of scanning (patient motion during image acquisition, inability to comply with breath hold requirements, inability to lie supine, claustrophobia)

o Because of the radiation exposure issues careful consideration should be given to other imaging modalities in pregnant women and children

Biosafety issues

● Ordering and imaging providers are responsible for considering safety issues prior to the cardiac CT exam. One of the most significant considerations is the requirement for intravascular iodinated contrast material, which may have an adverse effect on patients with a history of documented allergic contrast reactions or atopy, as well as on individuals with renal impairment, who are at greater risk for contrast induced nephropathy. In addition, radiation safety issues including cumulative exposure to ionizing radiation should be considered.

Ordering issues

● 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.

CLINICAL 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

o 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 left ventricular function in patients with suspected or established cardiomyopathy when all other non-invasive imaging is not feasible or technically suboptimal

o Other modalities providing non-invasive evaluation of left ventricular function include transthoracic and transesophageal echocardiography, blood pool imaging (MUGA or First pass) and cardiac MRI; OR

● To assess right ventricular function in patients with suspected right ventricular dysfunction when all other non-invasive imaging is not feasible or technically suboptimal

o Other modalities providing non-invasive evaluation of right ventricular 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

o 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

o 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

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 6 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 6 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

The following codes may be applicable to cardiac imaging and may not be all-inclusive. Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

 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 should be reported if FFR is estimated from CCTA data.

GENERAL INFORMATION

Scope of this Guideline

The guideline addresses the appropriate application of coronary CT angiography (CCTA) and CT derived fractional flow reserve (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.

Imaging Considerations

Coronary CT angiography provides direct images of the coronary arteries (anatomical imaging); as such, it differs from more established noninvasive approaches to evaluation of the coronary arteries. Both  myocardial perfusion imaging (MPI) and stress echocardiography (stress echo), for example, do not directly image the coronary arteries, but instead evaluate a parameter which is thought to reflect coronary blood flow to the myocardium and thereby infer the presence (or absence) of coronary stenosis (physiological imaging). In the case of MPI, myocardial uptake of an isotope is evaluated; whereas, with stress echo, decreased myocardial contractile reserve is assumed to be ischemic and therefore indicative of coronary stenosis.

Coronary CT angiography has been compared to stress echo and MPI and has been found to be non-inferior, or superior, depending on the study and the endpoints evaluated. Coronary CT angiography offers advantages over older approaches including shorter patient throughput times and lower radiation exposure (in the case of MPI). Furthermore, the negative predictive value of CCTA is very high (93%-100%). Coronary CT angiography also has limitations including the need to use iodinated contrast agents (which may limit use in patients with renal impairment) and the reduction of image quality in morbidly obese patients, those with heavy coronary calcium burdens and those with coronary stents. Beta blockers are frequently required to slow heart rate, and claustrophobic patients may have difficulty with scanning protocols.

The ability to measure fractional flow reserve by CT (FFR-CT) has the potential to expand the clinical application of CCTA. Fractional flow reserve by CT adds a physiological dimension to the CCTA such that coronary stenosis can be visualized anatomically and then evaluated for flow limiting significance. Thus, the availability of FFR-CT would be expected to assist with decisions regarding subsequent care including the need for coronary angiography, the likelihood of benefit from revascularization, etc. FFR-CT cannot be performed as a stand-alone service, but rather is available (if indicated) to patients who have undergone CCTA. Currently, FFR-CT calculations are performed at a location physically removed from the imaging site following electronic transmission of the imaging data. Results are usually available within 24 hours, but shorter turnaround times are feasible on request.

Recent literature comparing CCTA combined with FFR-CT to traditional noninvasive coronary artery disease evaluation has signaled that the former approach is non-inferior in terms of clinical endpoints and may offer advantages in terms of cost of care and radiation exposure.

CLINICAL INDICATIONS

The use of CT Coronary Angiography (CCTA), with or without Fractional Flow Reserve assessed by CT (FFR-CT), may be appropriate 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 “symptomatic” when ONE of the following (1-4) applies:

1. Chest pain

o With intermediate or high pretest probability of coronary artery disease; OR

o With low or very low pretest probability of coronary artery disease and high risk of coronary artery disease (SCORE)

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

o With moderate or high risk of coronary artery disease (SCORE)

3. Other symptoms: palpitation, nausea, vomiting, anxiety, weakness, fatigue, or any of the following symptoms when induced by exercise: dizziness, lightheadedness, or near syncope

o With high risk of coronary artery disease (SCORE)

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

o Abdominal aortic aneurysm; OR

o Chronic renal insufficiency or renal failure; OR

o Diabetes mellitus; OR

o Established and symptomatic peripheral vascular disease; OR

o Prior history of cerebrovascular accident (CVA), transient ischemic attack (TIA), carotid endarterectomy (CEA), or high-grade carotid artery 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 coronary artery disease in patients with left ventricular ejection fraction (LVEF) < 55% and low to moderate coronary artery disease risk (using standard methods of risk assessment, such as the SCORE risk calculation) in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy

o Patients with high coronary artery disease risk should undergo cardiac catheterization

Preoperative evaluation for patients undergoing non-coronary cardiac surgery

● Evaluation of symptomatic or asymptomatic patients at moderate coronary artery 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

o 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:

o Patient is symptomatic

o During testing the patient had exercise-induced chest pain, ST segment change, abnormal blood pressure response, or complex ventricular arrhythmias

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

● When BOTH of the following apply:

o Patient is symptomatic

o 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 Stress Echo within the past 60 days

● When BOTH of the following apply:

o Patient is symptomatic

o 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 pre-excitation syndrome) would render an exercise treadmill test (without imaging) uninterpretable

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

● When no coronary artery disease imaging evaluation (MPI, cardiac PET, stress echo, CCTA, or coronary angiography) has been performed within the preceding 60 days

 
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