Aetna Coverage Policy
Aetna considers cardiac computed tomography (CT) angiography of the coronary arteries using 64-slice or greater medically necessary for the following indications:
- Rule out obstructive coronary stenosis in symptomatic persons with a low or intermediate pre-test probability of coronary artery disease or atherosclerotic cardiovascular disease by Framingham risk scoring, Pooled Cohort Equations, or by American College of Cardiology (ACC) criteria (see Appendix), with any of the following indications:
- Evaluation of persons with nonacute chest pain who can not perform or have contraindications to exercise and pharmacological stress testing (see Appendix); or
- Evaluation of persons with chest pain presenting to the emergency department in persons without acute ECG changes or positive coronary markers when an imaging stress test or coronary angiography are being deferred as the initial imaging study.
- Rule out obstructive coronary stenosis in persons with a low or intermediate pre-test probability of coronary artery disease or atherosclerotic cardiovascular disease by Framingham risk scoring, Pooled Cohort Equations, or by American College of Cardiology (ACC) criteria (see Appendix) with a positive (i.e., greater than or equal to 1 mm ST segment depression) stress test.
- Evaluation of asymptomatic persons at an intermediate pre-test probability of coronary heart disease or atherosclerotic cardiovascular disease by Framingham risk scoring or Pooled Cohort Equations (see Appendix) who have an equivocal or uninterpretable exercise or pharmacological stress test or have resting electrocardiogram (ECG) changes (such as left bundle branch block (LBBB), pathologic q-waves, or right bundle branch block (RBBB) with left anterior fascicular block (LAFB) in which coronary artery disease (CAD) is a possible etiology.
- Pre-operative assessment of persons scheduled to undergo 'high-risk" non-cardiac surgery, where an imaging stress test or invasive coronary angiography is being deferred unless absolutely necessary. The ACC defines high-risk surgery as emergent operations, especially in the elderly, aortic and other major vascular surgeries, peripheral vascular surgeries, and anticipated prolonged surgical procedures with large fluid shifts and/or blood loss involving the abdomen and thorax.
- Pre-operative assessment for planned non-coronary cardiac surgeries including valvular heart disease, congenital heart disease, and pericardial disease, in lieu of cardiac catheterilzation as the initial imaging study, in persons with low or intermediate pretest risk of obstructive CAD.
- Detection and delineation of suspected coronary anomalies in young persons (less than 30 years of age) with suggestive symptoms (e.g., angina, syncope, arrhythmia, and exertional dyspnea without other known etiology of these symptoms in children and adults; dyspnea, tachypnea, wheezing, periods of pallor, irritability (episodic crying), diaphoresis, poor feeding and failure to thrive in infants).
- Calculation of fractional flow reserve (HeartFlow FFRCT) for persons who have a coronary CTA that has shown coronary artery disease of uncertain functional significance, or is non-diagnostic.
Aetna considers CT angiography of cardiac morphology for pulmonary vein mapping medically necessary for the following indications:
- Evaluation of persons needing biventricular pacemakers to accurately identify the coronary veins for lead placement.
- Evaluation of the pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation (pre- and post-ablation procedure).
Aetna considers CT angiography medically necessary for preoperative assessment of the aortic valve annulus prior to anticipated transcatheter aortic valve replacement (TAVR).
Aetna considers cardiac CT for evaluating cardiac structure and morphology medically necessary for the following indications
- Anomalous pulmonary venous drainage;
- Evaluation of other complex congenital heart diseases;
- Evaluation of sinus venosum atrial-septal defect;
- Kawasaki's disease;
- Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart diseases;
- Pulmonary outflow tract obstruction;
- Suspected or known Marfan's syndrome;
- Evaluation of suspected native or prosthetic cardiac valve dysfunction when echocardiographic imaging is inconclusive or there is suspicion for paravalvular abscess formation.
Aetna considers cardiac CT angiography experimental and investigational for persons with any of the following contraindications to the procedure because its effectiveness for indications other than the ones listed above has not been established:
- Body mass index (BMI) greater than 40 (except when 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized).
- Inability to image at desired heart rate (under 80 beats/min), despite beta blocker administration.
- Person with allergy or intolerance to iodinated contrast material
- Persons in atrial fibrillation (except when rate-controlled and 3rd generation Dual-Source CT (DSCT) 120-kv tube voltage is utilized).or with other significant arrhythmia.
- Persons with extensive coronary calcification by plain film or with prior Agatston score greater than 1000.
- Aetna considers cardiac CT angiography using less than 64-slice scanners experimental and investigational because the effectiveness of this approach has not been established.
- Aetna considers coronary CT angiography experimental and investigational for screening of asymptomatic persons, evaluation of atherosclerotic burden, evaluation of persons at high pre-test probability of coronary artery disease, evaluation of stent occlusion or in-stent restenosis, evaluation of persons with an equivocal PET rubidium study, identification of vulnerable plaques, monitoring of atheroma burden, and for all other indications (e.g., atrial angiosarcoma) because its effectiveness for these indications has not been established. Note: The selection of CT angiography should be made within the context of other testing modalities such as stress myocardial perfusion images or cardiac ultrasound results so that the resulting information facilitates the management decision and does not merely add a new layer of testing.
Aetna considers a single calcium scoring by means of low-dose multi-slice CT angiography, ultrafast [electron-beam] CT, or spiral [helical] CT medically necessary for screening the following:
- asymptomatic persons age 40 years and older with diabetes; or asymptomatic persons with an intermediate (10 % to 20 %) 10-year risk of cardiac events based on Framingham Risk Scoring or Pooled Cohort Equations (see Appendix).
- Repeat calcium scoring is considered medically necessary only if the following criteria are met: member’s most recent coronary artery calcium (CAC) scan result was zero, member's most recent CAC scan was at least 5 years ago, and discovery of coronary calcium would change management. Otherwise, serial or repeat calcium scoring is considered experimental and investigational.
- Aetna considers calcium scoring by means of low-dose CT angiography medically necessary for persons who meet criteria for diagnostic cardiac CT angiography to assess whether an adequate image of the coronary arteries can be obtained.
- Aetna considers calcium scoring of the aortic valve medically necessary in the setting of persons with suspected paradoxical low-flow, low-gradient symptomatic severe aortic stenosis when transthoracic echocardiography is inconclusive.
Aetna considers calcium scoring (e.g., with ultrafast [electron-beam] CT, spiral [helical] CT, and multi-slice CT) experimental and investigational for all other indications because of insufficient evidence in the peer-reviewed published medical literature.
| CPT Codes covered if the selection criteria are met:
|| Code Description
||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
||Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium [not covered for serial or repeat calcium scoring]
||Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assesment of cardiac function, and evaluation of venous structure, if performed
||Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed
||Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed
Table 1 can be used to assess if a person has a low or very low pre-test probability of CAD. Alternatively, pre-test probability of CAD can be assessed using the Framingham Risk Scoring Tool, with low risk defined as a 10-year risk of less than 10 %. (For details on Framingham Risk Scoring, see appendix to CPB 0381 - Cardiac Disease Risk Tests.) Or 10-year pretest probability of atherosclerotic cardiovascular disease (ASCVD) can be estimated using Pooled Cohort equations from a downloadable spreadsheet and a web-based available at Cardio Vascular Risk Calculator and Cardio Vascular Prevention Guideline Tools.
Table 1: ACC Criteria for Pre-test Probability of CAD by Age, Gender and Symptoms Footnotes for coronary artery disease (CAD)†
||Typical / Definite Angina Pectoris
||Atypical / Probable Angina Pectoris
||Nonanginal Chest Pain
- High: greater than 90% pre-test probability
- Intermediate: between 10% and 90% pre-test probability
- Low: between 5% and 10% pre-test probability
- Very low: less than 5% pre-test probability
† No data exist for patients less than 30 years or greater than 69 years, but it can be assumed that prevalence of CAD increases with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities slightly outside the high or low range.
Source: Adapted from Taylor et al., 2010
List 1: Clinical Classification of Chest Pain:
Typical angina (definite):
- Substernal chest discomfort with a characteristic quality and duration; and
- Provoked by exertion or emotional stress; and
- Relieved by rest or nitroglycerin
Atypical angina (probable):
- Meets 2 of the above criteria.
Non-cardiac chest pain:
- Meets 1 or none of the above criteria.
Source: Snow et al, 2004.
List 2: Contraindications to Exercise Stress Testing:
The following contraindications to exercise stress testing are from the AHA/ACC guidelines:
- Acute aortic dissection
- Acute myocardial infarction (within 2 days)
- Acute myocarditis or pericarditis
- Acute pulmonary embolus or pulmonary infarction
- Symptomatic severe aortic stenosis
- Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
- Uncontrolled symptomatic heart failure
- Unstable angina not previously stabilized by medical therapy.
In addition, exercise stress testing is not useful in persons who are unable to exercise, persons on digoxin, persons who have a cardiac conduction abnormality that prevents achievement of an adequate heart rate response, persons on a medication (e.g., beta blockers, other negative chronotropic agents) that can not be stopped which prevent achievement of an adequate heart rate response, and persons with an uninterpretable electrocardiogram. The American College of Cardiology defines an uninterpretable electrocardiogram as a ventricular paced rhythm, complete left bundle branch block, ventricular preexcitation arrhythmia (Wolfe Parkinson White syndrome), or greater than 1 mm ST segment depression at rest.
List 3: Contraindications to Pharmacological Stress Testing:
The following are contraindications to adenosine or dipyridamole (Persantine) stress testing:
- Active bronchospasm or reactive airway disease;
- Patients taking Persantine (contraindication to adenosine stress testing);
- Patients using methylxanthines (e.g., caffeine and aminophylline) (In general, patients should refrain from ingesting caffeine for at least 24 hours prior to adenosineor dipyridamole administration);
- Severe bradycardia (heart rate less than 40 beats/min);
- Sick sinus syndrome or greater than than first-degree heart block (in persons without a ventricular-demand pacemaker);
- Systolic blood pressure less than 90 mm Hg.
The following are contraindications to dobutamine stress testing:
- Atrial tachyarrhythmias with uncontrolled ventricular response;
- History of ventricular tachycardia;
- Left bundle branch block;
- Recent (within the past week) myocardial infarction;
- Significant aortic stenosis or obstructive cardiomyopathy;
- Thoracic aortic aneurysm;
- Uncontrolled hypertension;
- Unstable angina.
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