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Blue Cross Blue Shield plans by state
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Blue Cross Blue Shield Coverage Policies for Cardiac CT by State


Alabama

Updated 1/23/2019

No Stand alone policy for CCTA posted to website.

Policy No. 645, Noninvasive Fractional Flow Reserve by Coronary Computed Tomographic Angiography; Last reviewed May 2018

Effective for dates of service on and after August 14, 2017: The use of noninvasive fractional flow reserve* following a positive coronary computed tomography angiography meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage when used to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of coronary artery disease (i.e. suspected or presumed stable ischemic heart disease). 

The use of noninvasive fractional flow reserve does not meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage when the criteria outlined above is not met and is considered investigational. 

*NOTE: Fractional flow reserve using coronary computed tomography angiography requires at least 64-slice coronary computed tomography angiography and cannot be calculated when images lack sufficient quality (e.g., body mass index, >35 kg/m2). The presence of dense arterial calcification or an intracoronary stent can produce significant beam-hardening artifacts and may preclude satisfactory imaging. The presence of an uncontrolled rapid heart rate or arrhythmia hinders the ability to obtain diagnostically satisfactory images. Evaluation of the distal coronary arteries is generally more difficult than visualization of the proximal and mid-segment coronary arteries due to greater cardiac motion and the smaller caliber of coronary vessels in distal locations.

Policy No. 646, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed September 2018  (Coronary Artery Calcium Scoring) 

Computed tomography, heart, without contrast material including image post-processing and quantitative evaluation of coronary calcium may be considered medically necessary when a CCT or CCTA meets the coverage criteria, but when a review of the initial non-contrast CT images is reviewed it is determined that based on the calcium volume the patient is not a candidate for the arterial phase component of the study. (In this case only code 75571 should be reported.)

The use of computed tomography to detect coronary artery calcification as a stand-alone test is considered not medically necessary and investigational.


Alaska (Premera)

Updated 1/23/2019

No current policy listed for cardiac CT or calcium score.


Arizona

Updated 1/23/2019

Contrast Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation; Last reviewed October 30, 2018

CT angiography for evaluation of a suspected anatomical coronary artery anomaly will be reviewed by the medical director(s) and/or clinical advisor(s).

Contrast-enhanced coronary CT angiography for evaluation of a suspected anatomical coronary artery anomaly is considered medically necessary with documentation of ALL of the following:  

  • Unexplained dyspnea, chest pain, palpitations, recurrent syncope, arrhythmia or cardiac arrest
  • Current diagnostic tests, including chest X-ray, treadmill stress test, holter and/or event monitor, are inconclusive or normal, or images from MRI or TEE are technically limited. 
  • Contrast-enhanced coronary CT angiography for the emergency evaluation of individuals with acute chest pain and without known coronary artery disease is considered medically necessary.   
  • Contrast-enhanced coronary CT angiography for evaluation of a suspected aortic artery dissection or ruptured aortic aneurysm is considered medically necessary when ultrasound imaging is suboptimal or non-diagnostic. 
  • Contrast-enhanced coronary CT angiography for evaluation of a suspected pulmonary embolism in a symptomatic individual is considered medically necessary. 

Contrast-enhanced coronary CT angiography for evaluation of congenital heart defects, including cardiac chambers, valves, great vessels and vasculature is considered medically necessary as part of the pre- and post-operative assessment for cardiac surgery with documentation of ANY of the following

  • Congenital heart disease with contraindications to cardiac MRI (e.g., pacemaker)
  • Evaluation of coronary heart abnormalities with respect to origin and distribution (e.g., anomalous coronary artery arising from the pulmonary artery, left coronary artery from the right sinus of Valsalva)
  • Following coronary artery implantation after aortic root replacement or after transposition of the great artery repair
  • Primary evaluation of vascular ring or pulmonary artery sling lesions
  • Evaluation of the pulmonary artery in an individual with pulmonary atresia, hypoplasia or agenesis of the pulmonary artery
  • Following stent implantation in the pulmonary artery or aortic arch
  • Suspected aortic arch abnormality
  • Need to visualize extracardiac structures related to the congenital heart defect (e.g., tracheobronchial tree, esophagus, lung parenchyma)
  • Complex congenital heart defect to evaluate ventricular function 

Contrast-enhanced coronary CT angiography for evaluation of the left atrium prior to catheter ablation for atrial fibrillation is considered medically necessary.

Contrast-enhanced coronary CT angiography for coronary artery evaluation for all indications not previously listed or if above criteria not met is considered experimental or investigational based upon:

  1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and
  2. Insufficient evidence to support improvement of the net health outcome, and
  3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives. 

Examples include, but are not limited to: 

  • Coronary artery bypass graft patency
  • Coronary artery stenosis
  • Measurement of cardiac perfusion
  • Evaluation of coronary artery disease or atherosclerosis in an asymptomatic or symptomatic individual
  • Screening for coronary artery disease or atherosclerosis in an asymptomatic individual 

Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; Last reviewed June 19, 2018

The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography to guide decisions about the use of invasive coronary angiography in individuals with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic heart disease) is considered medically necessary

The use of noninvasive fractional flow reserve for all other indications not previously listed or if above criteria not met is considered experimental or investigational based upon: 

  1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and
  2. Insufficient evidence to support improvement of the net health outcome, and
  3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and
  4. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and
  5. Insufficient evidence to support improvement outside the investigational setting.

No current policy for CAC posted to website.


Arkansas

Updated 1/23/2019

An outpatient diagnostic imaging program is active (since September 1, 2006) for individual and group members of Arkansas Blue Cross and Blue Shield health plans, except for members of Medi-Pak, Medi-Pak Advantage, Access Only, AR Health (where Medicare is primary), BlueCard (check with home plan if not Arkansas) and the Federal Employee Program (FEP). 

Physicians are required to secure prior approval for the following outpatient procedures: CT Scan, MRI/MRA, Nuclear Cardiology and PET Scan. 

Arkansas Blue Cross utilizes AIM Specialty Health - an independent company - to provide prior approval of health plan coverage services.


California (Blue Shield)

Updated 1/23/2019

Policy 6.01.43, Contrast Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation; effective November 1, 2018

Contrast-enhanced coronary computed tomography angiography (CCTA) may be considered medically necessary for:

  • Evaluation of patients without known coronary artery disease and acute chest pain in the emergency department setting.
  • Evaluation of patients with stable chest pain and meeting guideline criteria for a noninvasive test in the outpatient setting (see Policy Guidelines). 
  • Evaluation of anomalous (native) coronary arteries in patients in whom they are suspected.
  • Considered investigational for all other indications.
Policy 6.01.03, Computed Tomography to Detect Coronary Artery Calcification; effective November 1, 2018
 
No CAC coverage – investigational.
 
Policy 6.01.59, Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; effective July 2018 
 
The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic heart disease). 
 
The use of noninvasive fractional flow reserve not meeting the criteria outlined above is considered investigational.

California (Anthem)

Updated 1/23/2019

(As of  January 2019, coronary artery imaging policy was removed from Anthem website) 

Previous policy:

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Colorado (Anthem)

Updated 1/23/2019

(As of  January 2019, coronary artery imaging policy was removed from Anthem website) 

Previous policy:

 CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Connecticut (Anthem)

As of January 2019, Coronary artery imaging policy was removed from Anthem Website. 

Previous policy:

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Delaware (Highmark)

Updated 1/23/2019

Policy X 176-001; Cardiac: Cardiac CT, Coronary CTA, and CT for Coronary Calcium (CAC); effective January 1, 2019

Computed tomography (CT) calcium scoring for coronary artery disease (CAD) screening, please refer to Medical Policy X-173, Cardiac: General Guidelines; Table 1. 

Coronary calcium scoring as a stand- alone test is considered experimental and investigational in asymptomatic patients with any degree of CAD risk and therefore non-covered. 

Coronary computed tomography angiography (CCTA) may be considered medically necessary for the following indications:

  • Symptomatic individuals who have a low or intermediate pretest probability of CAD. 
  • Low or intermediate pre-test probability of coronary disease with persistent symptoms after a stress test;
  • Replace performance of invasive coronary angiogram in individuals with low risk of CAD (i.e. Pre-op non-coronary surgery)
  • For symptomatic individuals to evaluate post-CABG graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed, such as in early graft failure.
  • For symptomatic individuals with unsuccessful conventional coronary angiography (i.e. locate a coronary artery, graft, identify the course of an anomalous coronary artery.
  • Re-do Coronary Artery Bypass Graft (CABG) or to identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.
  • Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels.
  • Anomalous coronary artery or arteries suspected for diagnosis or to plan treatment and less than age 40 with a history that includes ONE or more of the following:
    • Persistent exertional chest pain and normal stress test; or
    • Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery; or
  • Resuscitated sudden death and contraindications for conventional coronary angiography.
  • Unexplained new onset of heart failure.
  • Evaluation of newly diagnosed congestive heart failure or cardiomyopathy.
  • No prior history of coronary artery disease, the ejection fraction is less than 50 percent, and low or intermediate risk on the pre-test probability assessment, and
    • No exclusions to cardiac CT angiography.
    • No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy
  • Ventricular tachycardia of six (6) beat runs or greater if CCTA will replace conventional invasive coronary angiography.
  • Equivocal coronary artery anatomy on conventional cardiac catheterization.
  • Newly diagnosed dilated cardiomyopathy.
  • Preoperative assessment of the coronary arteries in patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.
  • Vasculitis/Takayasu’s /Kawasaki’s disease

The following are relative contraindications for cardiac/coronary CT:

  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block)
  • Multifocal atrial tachycardia (MAT)
  • Inability to lie flat
  • Body mass index (BMI) of 40 or more.
  • Inability to obtain a heart rate less than 65 beats per minute after beta-blockers.
  • Inability to hold breath for at least eight seconds.
  • Renal Insufficiency.
  • Asymptomatic patients and routine use in the evaluation of the coronary arteries following heart transplantation.
  • CCTA should not be performed if there is extensive coronary calcification (calcium score greater than 1000).
  • Evaluation of coronary stent patency (metal artifact limits accuracy), less than three (3.0) mm.
  • Evaluation of left ventricular function following myocardial infarction or in chronic heart failure.     
  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block);
  • High pre-test probability for CAD - rather, these patients should undergo conventional coronary angiography, especially if an interventional procedure (e.g., PCI) is anticipated.
  • Identification of plaque composition and morphology.
  • Myocardial perfusion and viability studies
  • Preoperative assessment for non-cardiac, nonvascular surgery.
  • Routine follow-up of asymptomatic or stable symptoms of CAD with CCTA.
  • There is insufficient evidence to support routine use of coronary computed tomography angiography (CCTA) in the evaluation of the coronary arteries following heart transplantation.

CCTA for any other indication not listed above is considered not medically necessary.

Fractional flow reserve by computed tomography (CT) may be considered medically necessary for the following indications for FFR-CT:

  • To further asses CAD seen on a recent CCTA that is of uncertain physiologic significance.

FFR for any other indication not listed above is considered not medically necessary. 

CT of the heart for cardiac vein or pulmonary vein may be considered medically necessary for the following indications:

  • Cardiac vein identification for lead placement in patients needing left ventricular pacing
  • If echocardiogram is inconclusive for cardiac, pericardial tumor or mass, cardiac thrombus pericarditis/constrictive pericarditis or complications of cardiac surgery
  • Clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC), especially if patient has presyncope or syncope if the clinical suspicion is supported by established criteria for ARVD
  • Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.

CT of the heart for cardiac vein or pulmonary vein for any other indication not listed above is considered not medically necessary.

CT heart for congenital heart disease may be considered medically necessary for the following indications:

  • Coronary artery anomaly evaluation
  • Cardiac catheterization was performed, and not all coronary arteries were identified.
  • Thoracic arteriovenous anomaly evaluation.
  • A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.
  • Complex adult congenital heart disease evaluation.
    • No cardiac CT or cardiac MRI has been performed, and there is a contraindication to cardiac MRI
    • A cardiac CT or cardiac MRI was performed one year ago or more.

CT of the heart for Congenital Heart Disease for any other indication not listed above is considered not medically necessary

Transcatheter aortic valve replacement (TAVR):

The following tests may be considered medically necessary once a decision has been made for aortic valve replacement (TAVR) to determine if a patient is a candidate for TAVR:

  • CTA of chest, abdomen and pelvis; and
  • Cardiac CT to measure the aortic annulus
  • Coronary CTA to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.

Post TAVR:

  • TAVR follow-up may be considered medically necessary at 3 months, at one year post-procedure, and annually thereafter.

Updated 1/23/19

04-70450-03, Computed Tomographic Angiography Heart; Last reviewed 4/27/18, last revised May 15, 2018

Computed tomographic angiography (CTA/CCTA) meets the definition of medical necessity when the member meets appropriate use criteria, for indications with an appropriate use score of 4 to 9. 

04-70450-26, Computed Tomography Heart; Last reviewed 4/26/18; effective 5/15/18

Cardiac computed tomography (heart CT) meets the definition of medically necessity when the member meets the appropriate use criteria*, for indications with an appropriate use score of 4-9.

04-78000-22; Noninvasive Fractional Flow Reserve Measurement; 12/8/17

The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography meets the definition of medical necessity to guide decisions about the use of invasive coronary angiography in members with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive fractional flow reserve for all other indications when the above criteria are not met is considered experimental or investigational. The evidence is insufficient to determine that noninvasive fractional flow reserve results in improvement in net health outcome.

04-70450-02, Computed Tomography to Detect Coronary Artery Calcification; Last revised 6/15/2018

No CAC coverage.

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/19

Uses NIA/Magellan indications/pre-certification; no published individual medical policy for CT/CTA


Idaho (Blue Cross)

Updated 1/23/19

Policy 6.01.59, Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; Effective 5/30/2018

The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of coronary artery disease (ie, suspected or presumed stable ischemic heart disease).

The use of noninvasive fractional flow reserve not meeting the criteria outlined above is considered investigational.

NOTE:  No stand alone policy found for CCTA 

Policy 6.01.03 – Computed Tomography to Detect Coronary Artery Calcification; Effective  September 9, 2018

No CAC coverage – investigational.


Idaho (Regence)

Updated 1/23/19 No updated policy. 

Previous Policy:   Anomalous coronary artery mapping; ED evaluation of CAD in patients with acute chest pain without known CAD (indications as of Nov 2015; no Coronary CTA current policy published on website). 

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed October 2018

No CAC coverage.

Updated 1/23/19

RAD 604.007 Coronary Computed Tomography Angiography, Including Noninvasive Fractional Flow Reserve; effective 10/15/2018.

Contrast-enhanced coronary computed tomography angiography (CCTA) for evaluation of individuals without known coronary artery disease (CAD) who present with acute chest pain in the emergency room or emergency department setting may be considered medically necessary.

Contrast-enhanced CCTA for evaluation of symptomatic individuals with suspected ischemic heart disease, who meet guideline criteria for a noninvasive test in the outpatient setting may be considered medically necessary (should be performed on individuals with at least intermediate risk for coronary artery disease (10%-90% risk by standard risk prediction instruments/pre-test probability assessments). The choice of test will depend on: Interpretability of the electrocardiogram; and Ability to exercise; and Presence of comorbidities. 

Contrast-enhanced CCTA for evaluation of anomalous (native) coronary arteries in individuals in whom abnormal coronary arteries are suspected may be considered medically necessary.

CCTA, with or without contrast enhancement, as an adjunct to other testing, may be considered medically necessary for the evaluation of cardiac structure and function to:

  • Assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • Assess suspected arrhythmogenic right dysplasia, left ventricular function when cardiomyopathy is suspected or established, and right ventricular function when right ventricular dysfunction is suspected in individuals with technically limited images from echocardiography (ECG), magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE)
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE
  • Assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned.
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE.
  • Assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, pericardial effusion, or complications of cardiac surgery in patients) with technically limited images from ECG, MRI, or TEE.
  • Perform non-invasive coronary vein mapping prior to placement of a bi-ventricular pacemaker.
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation.
  • Evaluate cardiac aneurysm and pseudoaneurysm.
  • Evaluate thoracic aortic aneurysm (TAA) (such as suspected aneurysm in individuals who have not undergone computed tomography (CT) or MRI within the preceding 60 days, confirmed TAA in individuals with new or worsening symptoms, or suspected aortic dissection (with or without worsening symptoms or pre-operative planning).
  • Assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

CCTA, with or without contrast enhancement, for coronary artery evaluation is considered experimental, investigational and/or unproven for all other indications, including but not limited to:

  • Screening asymptomatic individuals for CAD.
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.
  • Evaluating individuals for any other indication not listed above, including but not limited to high or low pretest probability (low risk defined as <10% and high risk as >90%) of CAD.

CCTA performed using a multi-detector row CT scanner with less than 64-slice scanner is considered experimental, investigational and/or unproven.

Noninvasive Fractional Flow Reserve Computed Tomography

The use of noninvasive fractional flow reserve (FFR) following a positive CCTA may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of CAD (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive FFR computed tomography (FFRCT) simulation not meeting the criteria above is considered experimental, investigational and/or unproven.

If CT imaging is done of the blood vessels it is not necessarily a CCTA. A CCTA must include reconstruction post-processing of the angiographic images and interpretations, which is a key distinction between a CCTA and conventional CT. If the reconstruction post-processing is not done, it is not considered a CCTA study.

 RAD 604.009, Computed Tomography to Detect Coronary Artery Calcification, effective 12/15/2018

The use of computed tomography (CT) to detect coronary artery calcification is considered experimental, investigational and/or unproven.

 Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/2019

No current published policy for CT/CTA. 

Previous Policy: 

Policy 06.01.20 – Computed Tomography Angiography of the Coronary Arteries, Last reviewed April 2016; (no longer listed on the web as of January 10, 2018).  Policy likely under revision now.

The use of CCTA is considered not medically necessary as a screening study for asymptomatic individuals because its effectiveness for this indication has not been established.

Computerized Tomographic Angiography Coronary Arteries (CCTA) may be considered medically necessary for the following indications:

Evaluation of suspected cardiac chest pain when all of the following are met: 

  • No known history of coronary artery disease (CAD) AND
  • Low or intermediate pre-test probability of coronary artery disease (CAD) (using Framingham risk score calculation) AND 
  • ECG normal/non-diagnostic for etiology of chest pain

Evaluation of suspected coronary artery disease (CAD) including those individuals with prior abnormal cardiac testing (myocardial perfusion imaging (MPI) or stress echo: 

  • abnormal MPI or stress echo within the preceding 90 days suspected to be false positive on the basis of low coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation).
  • equivocal MPI or stress echo within the preceding 90 days who have low or intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation).
  • congestive heart failure/cardiomyopathy/left ventricular dysfunction
    • For exclusion of coronary artery disease in patients with left ventricular ejection fraction <55% and intermediate coronary heart disease risk in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy.
  • Evaluation for non coronary artery cardiac surgery
    • Individual with intermediate coronary heart disease risk and being evaluated for non coronary artery cardiac surgery (including valvular and ascending aortic surgery) to avoid an invasive angiogram. All the necessary pre-operative information can be obtained using cardiac CT. 
  • Congenital coronary artery anomalies
    • For evaluation of suspected congenital anomalies of the coronary arteries

Medical Policy 06.01.06, Coronary Artery Calcium Scoring; Last reviewed July 2018

Coronary artery calcium scoring by means of computed tomography is considered investigational for all indications.

Updated 1/23/2019

Contrast Enhanced CCTA for Coronary Artery Evaluation; Last revised November 2018

Contrast-enhanced coronary computed tomography angiography for evaluation of patients with:

  • symptoms of stable ischemic heart disease and meeting guideline criteria for a noninvasive test in the outpatient setting is considered medically necessary.  
  • without known coronary artery disease and acute chest pain in the emergency room/emergency department setting is considered medically necessary.
  • anomalous (native) coronary arteries in patients in whom they are suspected may be considered medically necessary.  

Contrast-enhanced coronary computed tomography angiography for coronary artery evaluation is considered experimental / investigational for all other indications.

CCTA with Selective Noninvasive Fractional Flow Reserve; Last revised September 2018

The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of coronary artery disease (ie, suspected or presumed stable ischemic heart disease). 

The use of noninvasive fractional flow reserve not meeting the criteria outlined above is considered experimental / investigational.

CT to Detect Coronary Artery Calcification; Last reviewed November 2017

No CAC coverage.

Updated 1/23/2019

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/2019

Policy No. 00153, Contrast Enhanced Computed Tomography for Coronary Artery Evaluation; Effective July 2, 2018

Coverage eligibility will be considered when using at least a 64-slice multidetector row helical computed tomographic scanner for ANY of the following conditions:

  • Evaluation of anomalous (native) coronary arteries in symptomatic patients when the results will impact treatment.
  • Assessment of suspected or established complex congenital heart disease including anomalies of coronary circulation, great vessels and cardiac chambers and valves.
  • Evaluation of pulmonary vein anatomy prior to invasive radio-frequency ablation for atrial fibrillation or flutter.
  • Evaluation of patients with acute chest pain who do not have known coronary artery disease (CAD) in the emergency room/emergency department (ED) settin
  • For exclusion of CAD in patients with left ventricular ejection fraction < 55% and low or intermediate coronary heart disease risk in patients whom CAD has not been excluded as the etiology of the cardiomyopathy. 
  • Patients at intermediate coronary heart disease risk (using standard methods of risk assessment such as Framingham or ACC criteria) being evaluated for non-coronary artery cardiac surgery (including valvular and ascending aortic surgery) to avoid an invasive angiogram, where all of the necessary preoperative information can be obtained using cardiac computed tomography (CT).
  • To evaluate patients with suspected CAD who have low or intermediate coronary heart disease risk and have had an equivocal myocardial perfusion imaging (MPI) or stress echo within the preceding 60 days.
  • To evaluate patients with suspected CAD who have a low coronary heart disease risk who have had an abnormal MPI or stress echo within the preceding 60 days suspected to be a false positive.
  • To evaluate patients with suspected stable ischemic heart disease with at least intermediate risk when no CAD imaging evaluation (e.g., MPI, cardiac positron emission tomography (PET), stress echocardiogragphy (SE), CCTA, or coronary angiography) has been performed within the preceding sixty (60) days.

When Services Are Considered Investigational Coverage is not available for investigational medical treatments or procedures, drugs, devices or biological products.

Based on review of available data, the Company considers contrast-enhanced CCTA for coronary artery evaluation to be investigational  for all other indications.

Policy No. 00031, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed December 2018

No CAC coverage – investigational

Policy No. 00537, CCTA with Selective Noninvasive Fractional Flow Reserve; effective October 2018

Based on review of available data, the Company may consider the use of noninvasive fractional flow reserve (FFR) following a positive coronary computed tomography angiography (CCTA) to guide decisions about the use of invasive coronary angiography (ICA) in patients with stable chest pain at intermediate risk of coronary artery disease (CAD i.e., suspected or presumed stable ischemic heart disease [SIHD]) to be eligible for coverage. 

When Services Are Considered Investigational Coverage is not available for investigational medical treatments or procedures, drugs, devices or biological products. 

The use of noninvasive fractional flow reserve (FFR) not meeting the criteria outlined above is considered to be investigational.

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/2019

6.01.035 Cardiac Computed Tomography and Coronary CT Angiography; last review 11/2017

The following indications for use of CT of the heart and CTA are based on the Appropriateness Criteria established by the American College of Cardiology Foundation. Computed tomography (CT) of the heart, with or without angiography, to evaluate cardiac structure and morphology for:

  • Congenital heart disorders;
  • Evaluation of pulmonary veins prior to a pulmonary vein isolation procedure for atrial fibrillation;
  • Identification of coronary veins prior to insertion of a biventricular pacemaker.

Computed tomography angiography (CTA) using scanners of 64 slices or greater for evaluating coronary circulation:

  • As an alternative to conventional invasive coronary angiography in patients who have had an equivocal stress ECG;
  • For the evaluation of suspected congenital anomalies of the coronary circulation;
  • For the evaluation of symptoms consistent with cardiac ischemia in patients determined to be at low to intermediate risk (Framingham criteria) for coronary artery disease;
  • Not recommended for screening in asymptomatic patients.

Policy 6.01.003; Computed Tomography to Detect Coronary Artery Calcification; Last reviewed February 2017; slated for review 2/21/19

The indications for the use of EBCT to detect coronary artery calcification have been updated based upon the Appropriateness Criteria established by the American College of Cardiology Foundation (2013) and include symptomatic individuals who have had an equivocal non-invasive workup where additional diagnostic information is required, but are not immediate candidates for cardiac catheterization; and asymptomatic adults at intermediate risk of a cardiac event (10% to 20% ten year risk).

Updated 1/23/19

Policy 831, CCTA and CT Derived Fractional Flow Reserve

 

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

The use of CT Coronary Angiography (CCTA), with or without Fractional Flow Reserve assessed by CT (FFR-CT), may be MEDICALLY NECESSARY 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 policy, a patient is considered to be “symptomatic” when one of the following applies:

  1.  Chest pain
    •  With intermediate or high pretest probability of CAD
    •  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
    •  Chronic renal insufficiency or renal failure
    •  Diabetes mellitus
    •  Established and symptomatic peripheral vascular disease
    •  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

 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

 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 pre-excitation 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 

 Prior Authorization Information

 

 Inpatient

 For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

 

 Outpatient

 For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

 

 Outpatient
Commercial Managed Care (HMO and POS) The requirements of BCBSMA Radiology Management Program may require a precertification/prior authorization via AIM Specialty Health. These requirements are member-specific: Please verify member eligibility and requirements through Online Services by logging onto Provider Central. Refer to our Quick Tip for an overview of precertification and prior authorization requirements. Ordering clinicians should request pre-certification from AIM Specialty Health (see their FFR-CT policy) or call 1-866-745-1783 (when applicable). Prior authorization information for Medicare HMO Blue and Medicare PPO Blue is addressed in medical policy #923, High Technology Radiology and Sleep Disorder Management for Medicare Advantage Products.
Commercial PPO and EPO 
Indemnity Prior authorization is not required.

CPT Codes

Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

 

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

 

The following codes are included below for informational purposes only; this is not an all-inclusive list.

 

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

 

CPT Codes Code Description
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.

Policy 832, Cardiac CT for Quantitative Evaluation of Coronary Calcification

No coverage of CAC – investigational.  Follows AIM Guidelines for Advanced Cardiac Imaging.

 

Policy 833, Computed Tomography Cardiac (structure)

 

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

 Computed Tomography (CT) Cardiac (Structure) is considered MEDICALLY NECESSARY for the following conditions:

 

 Congenital heart disease

  • For evaluation of suspected or established congenital heart disease in patients whose echocardiogram is technically limited or non-diagnostic
  • For further evaluation of patients whose echocardiogram suggests a new diagnosis of complex congenital heart disease
  •  For evaluation of complex congenital heart disease in patients who are less than one year postsurgical correction
  • For evaluation of complex congenital heart disease in patients who have new or worsening symptoms and/or a change in physical examination
  • To assist in surgical planning for patients with complex congenital heart disease
  • 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 noninvasive 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
  •  In patients with established cardiac or para-cardiac mass (thrombus, tumor, etc.) who are clinically unstable
  •  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;
  •  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.
  •  In patients with suspected congenital pericardial disease.
  •  In patients with suspected pericardial effusion who have undergone echocardiography deemed to be technically suboptimal in evaluation of the effusion.
  •  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.
  •  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.
  •  In patients with confirmed thoracic aortic aneurysm / dilation with new or worsening signs/symptoms.
  •  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.
  •  In patients with suspected aortic dissection.
  •  In patients with confirmed aortic dissection who have new or worsening symptoms.
  •  In patients with confirmed aortic dissection in whom surgical repair is anticipated (to assist in preoperative planning)
  •  For ongoing surveillance of stable patients with confirmed aortic dissection who have not undergone imaging of the thoracic aorta within the preceding year.
  •  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.
  •  In patients who have sustained blunt chest trauma, penetrating aortic trauma or iatrogenic trauma as a result of aortic instrumentation.
  •  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

 Prior Authorization Information

 Inpatient

  •  For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

 Outpatient

  •  For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient

 

Outpatient
Commercial Managed Care (HMO and POS)  The requirements of BCBSMA Radiology Management Program may require a precertification/prior authorization via AIM Specialty Health. These requirements are member-specific: Please verify member eligibility and requirements through Online Services by 4 and Indemnity logging onto Provider Central. Refer to our Quick Tip for an overview of precertification and prior authorization requirements. Ordering clinicians should request pre-certification from AIM Specialty Health or call 1-866-745-1783 (when applicable). Prior authorization information for Medicare HMO Blue and Medicare PPO Blue is addressed in medical policy #923, High Technology Radiology and Sleep Disorder Management for Medicare Advantage Products. 
Commercial PPO and Indemnity

 

CPT Codes

Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

 

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

 

The following codes are included below for informational purposes only; this is not an all-inclusive list. 

 

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes Code Description
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 in the setting of congenital heart disease (including 3-D post-processing, assessment of left ventricular cardiac function, right ventricular structure and function and evaluation of venous structures, if performed)

Michigan

Updated 1/23/19

Contrast Enhanced Computed Tomography Angiography of the Heart and Coronary Arteries (effective May 2018)

CCTA may be done in an inpatient, outpatient or emergency room setting. The following patients are considered appropriate candidates for CT angiography by the American College of Cardiology:

  • Those with stress test results that are equivocal or discordant with other clinical evidence, in lieu of invasive coronary angiography
  • Those with low-intermediate risk acute chest pain in order to exclude coronary artery disease in the emergency department or inpatient setting
  • Those with new onset chest pain in low-intermediate risk patients in the outpatient setting
  • Symptomatic patients for the evaluation of coronary bypass graft or coronary stent patency, in order to facilitate decision making for invasive angiography
  • Those with suspected coronary anomalies
  • Patients scheduled for cardiac or major thoracic surgery, such as aortic valve replacement or aortic aneurysm repair, in order to exclude coronary artery disease, as an alternative to invasive coronary angiography
  • Patients with incomplete invasive catheterization results as an alternative to repeat invasive catheterization
  • Patients anticipating cardiac surgery who require an assessment of coronary or pulmonary venous anatomy:  This application of CTA for the coronary and pulmonary veins is primarily for pre-surgical planning.  Evaluation of 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 intracardiac catheter ablation of an arrhythmogenic focus. 

An additional indication for cardiac CT is for the assessment of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.  Examples of these conditions include, but are not limited to:

  • Anomalous pulmonary venous drainage
  • Other complex congenital heart diseases
  • Sinus venosum atrial septal defect
  • Kawasaki’s disease
  • Consideration for surgical repair of tetralogy of Fallot or other congenital heart disease.
  • Pulmonary outflow tract obstruction 
  • CCTA is also established for the evaluation of intra- and extra-cardiac structures, including but not limited to:
  • Evaluation of cardiac mass (suspected tumor or thrombus) and patients with technically limited images from echocardiogram, MRI or TEE.
  • Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, or complications of cardiac surgery) and patients with technically limited images from echocardiogram, MRI or TEE.
  • Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation (e.g., pulmonary vein isolation).
  • Non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluation of suspected aortic dissection or thoracic aortic aneurysm.
  • Evaluation of suspected pulmonary embolism.

Exclusions:

  • Those individuals who do not meet the criteria stated above.
  • For screening purposes
  • Multidetector CT scanners that have fewer than 64 detectors
  • Computed tomography of the heart, without contrast material, with quantitative evaluation of coronary calcium.  Calcium scoring reported in isolation is considered a screening service.  See JUMP policy “Computed Tomography to Detect Coronary Artery Calcification.”

No CAC coverage effective January 2018

Updated 1/23/2019

V 14 002; Last reviewed October 2017  Uses eviCore management guidelines effective August 1, 2018

The use of computed tomography angiography (CTA) for evaluation of coronary arteries may be considered MEDICALLY NECESSARY AND APPROPRIATE for ANY of the following indications:

  • As an alternative to invasive angiography, following a stress test that is equivocal or suspected to be inaccurate
  • Evaluation of suspected congenital anomalies of the coronary circulation
  • Evaluation of acute chest pain or symptoms consistent with acute cardiac ischemia
  • Assessment of coronary or pulmonary venous or arterial anatomy for pre-surgical planning. Examples of pre-surgical assessment include:
    • Coronary vein mapping prior to placement of biventricular pacemaker,
    • Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation,
    • Coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.

All other applications of computed tomography angiography (CTA) of the coronary arteries are considered EXPERIMENTAL/INVESTIGATIVE, including, but not limited to:

Screening for coronary artery disease (i.e., absence of signs or symptoms of disease)

V 09 003; Last reviewed September 2017

No CAC coverage - investigational

Updated 1/23/2019

Policy L.6.01.415, CCTA; Last updated 5/30/2018

Providers must be accredited by IAC or ACR.

A diagnosis of chest pain (acute or non-acute) is not in itself an eligible indication for performing CCTA.

CCTA using a 64-slice or greater CT scanner is considered medically necessary for the following:

Detection of CAD in Symptomatic Patients

1) Evaluation of chest pain syndrome

  • Intermediate pre-test probability of CAD (see Table A below) and electrocardiogram (ECG) (EKG) uninterpretable or unable to exercise

2) Evaluation of intra-cardiac structures

  • Evaluation of suspected coronary anomalies

3) Acute chest pain

  • Intermediate pre-test probability of CAD (see Table A below) and no electrocardiogram (ECG) (EKG) changes and serial enzymes negative

4) Abnormal electrocardiogram (ECG) (EKG)

  • Left bundle branch block/left ventricle hypertrophy with ST segment changes

Detection of CAD with Prior Test Results

1) Evaluation of chest pain syndrome:

  • Un-interpretable or equivocal stress test (exercise, perfusion, or stress echo)
  • Conventional angiography is unsuccessful or equivocal

Evaluation of Acute Chest Pain in the Emergency Room/Emergency Department

Acute chest pain in the Emergency Room/Emergency Department for patients with intermediate pre-test probability of CAD that meet ALL of the following criteria:

  • No known coronary artery disease
  • Normal or equivocal serum biomarkers such as creatine kinase-myocardial band, myoglobin and/or troponin I
  • Normal or equivocal ischemic electrocardiogram (ECG) (EKG) changes such as ST-segment elevation or depression ≥1mm in 2 or more contiguous leads, and or T-wave inversion ≥2ml

Evaluation of Cardiac Structure and Function

Morphology

  • Assessment of congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves
  • Evaluation of coronary arteries in patients with new onset heart failure to assess etiology

Evaluation of intra- and extra-cardiac structures

  • Evaluation of cardiac mass (suspected tumor or thrombus) and patients with technically limited images from echocardiogram, MRI or TEE
  • Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, or complications of cardiac surgery) and patients with technically limited images from echocardiogram, MRI or TEE
  • Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation (e.g., pulmonary vein isolation)
  • Non-invasive coronary vein mapping prior to placement of biventricular pacemaker or, placement of automatic implantable cardioverter defibrillator (AICD)
  • Non-invasive coronary arterial and venous bypass mapping, including internal mammary artery and bypass grafts prior to repeat cardiac vascularization

Evaluation of aortic and pulmonary disease

  • Evaluation of suspected aortic dissection or thoracic aortic aneurysm
  • Evaluation of suspected pulmonary embolism

Policy a.6.01.03; Last updated October 2018

No CAC coverage. 

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/19

Policy 6.01.59 Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; Next review 8/2019

The use of noninvasive fractional flow reserve following coronary computed tomography angiography to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of coronary artery disease (ie, suspected or presumed stable ischemic heart disease) may be considered medically necessary.

Updated 1/23/19

RAD 604.007 Coronary Computed Tomography Angiography, Including Noninvasive Fractional Flow Reserve; effective 10/15/2018.

Contrast-enhanced coronary computed tomography angiography (CCTA) for evaluation of individuals without known coronary artery disease (CAD) who present with acute chest pain in the emergency room or emergency department setting may be considered medically necessary.

Contrast-enhanced CCTA for evaluation of symptomatic individuals with suspected ischemic heart disease, who meet guideline criteria for a noninvasive test in the outpatient setting may be considered medically necessary (should be performed on individuals with at least intermediate risk for coronary artery disease (10%-90% risk by standard risk prediction instruments/pre-test probability assessments). The choice of test will depend on: Interpretability of the electrocardiogram; and Ability to exercise; and Presence of comorbidities. 

Contrast-enhanced CCTA for evaluation of anomalous (native) coronary arteries in individuals in whom abnormal coronary arteries are suspected may be considered medically necessary.

CCTA, with or without contrast enhancement, as an adjunct to other testing, may be considered medically necessary for the evaluation of cardiac structure and function to:

  • Assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • Assess suspected arrhythmogenic right dysplasia, left ventricular function when cardiomyopathy is suspected or established, and right ventricular function when right ventricular dysfunction is suspected in individuals with technically limited images from echocardiography (ECG), magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE)
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE
  • Assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned.
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE.
  • Assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, pericardial effusion, or complications of cardiac surgery in patients) with technically limited images from ECG, MRI, or TEE.
  • Perform non-invasive coronary vein mapping prior to placement of a bi-ventricular pacemaker.
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation.
  • Evaluate cardiac aneurysm and pseudoaneurysm.
  • Evaluate thoracic aortic aneurysm (TAA) (such as suspected aneurysm in individuals who have not undergone computed tomography (CT) or MRI within the preceding 60 days, confirmed TAA in individuals with new or worsening symptoms, or suspected aortic dissection (with or without worsening symptoms or pre-operative planning).
  • Assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

CCTA, with or without contrast enhancement, for coronary artery evaluation is considered experimental, investigational and/or unproven for all other indications, including but not limited to:

  • Screening asymptomatic individuals for CAD.
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.
  • Evaluating individuals for any other indication not listed above, including but not limited to high or low pretest probability (low risk defined as <10% and high risk as >90%) of CAD.

CCTA performed using a multi-detector row CT scanner with less than 64-slice scanner is considered experimental, investigational and/or unproven.

Noninvasive Fractional Flow Reserve Computed Tomography

The use of noninvasive fractional flow reserve (FFR) following a positive CCTA may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of CAD (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive FFR computed tomography (FFRCT) simulation not meeting the criteria above is considered experimental, investigational and/or unproven.

If CT imaging is done of the blood vessels it is not necessarily a CCTA. A CCTA must include reconstruction post-processing of the angiographic images and interpretations, which is a key distinction between a CCTA and conventional CT. If the reconstruction post-processing is not done, it is not considered a CCTA study.

 RAD 604.009, Computed Tomography to Detect Coronary Artery Calcification, effective 12/15/2018

The use of computed tomography (CT) to detect coronary artery calcification is considered experimental, investigational and/or unproven.

 1/23/2019

Medical Policy IV.62 CCTA; Last review August 2017; Next review August 20, 2019

Computed tomography angiography (CTA) of the coronary arteries may be considered medically necessary for ANY of the following indications: 

A.  Evaluation of a member with no known CAD, who presents with suspected cardiac chest pain and has a low to intermediate pretest probability of CAD based on Framingham risk scoring or American College of Cardiology (ACC) criteria.   

B.  Evaluation of a member with no known CAD, who is asymptomatic and has an intermediate pretest probability of CAD based on Framingham risk scoring or American College of Cardiology (ACC) criteria. 

C.  Evaluation of a member with or without CAD in whom exercise stress testing, stress echo or stress nuclear scan (including SPECT) is equivocal or indeterminate.

D.  Evaluation of a member with suspected cardiac chest pain or angina equivalent e.g. dyspnea, who has a history of coronary artery bypass graft surgery (CABG) or coronary artery stent placement. 

E.  Evaluation of a member to exclude CAD as the cause of ANY of the following clinical presentations: 

  1. Left bundle branch block (LBBB) OR
  2. congestive heart failure (CHF) OR
  3. systolic or diastolic myocardial dysfunction.   

F. Evaluation of suspected congenital anomalies of the coronary arteries. 

G. Evaluation of a member with suspected arrhythmogenic Right ventricular dysplasia (ARVD) to assess Right ventricular function and morphology. 

H.  Pre-operative evaluation of a member scheduled to undergo surgery for ANY of the following conditions:  

  1. valvular heart disease OR
  2. congenital heart disease OR
  3. pericardial disease.

I.  Pre-operative evaluation of a member scheduled to undergo surgery that is considered to be “high risk” due to ANY of the following: 

  • member is elderly OR
  • emergency operation OR
  • major vascular surgery such as aorta or other large vessels
  • major surgery involving the chest or abdomen

J.  Pre-operative evaluation of the aortic valve annulus prior to transcatheter aortic valve replacement (TAVR).

II.  Computed tomography angiography (CTA) of the coronary arteries for all other indications not listed above is considered Investigational as its effectiveness for other indications has not been established.

III. Heart flow fractional flow reserve calculation (HeartFlow FFRCT) following CTA coronary may be considered medically necessary to guide decisions about the use of invasive coronary angiography.

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/2019

Policy 149, CCTA; Effective 5/17/18

For symptomatic individuals who have a ‘very low’, ‘low’, or ‘intermediate’ pretest probability of CAD, CCTA may be used in the following situations: 

  • Unable to perform either an exercise or pharmacologic imaging stress test
  • Stress test (treadmill or imaging stress test) is uninterpretable, equivocal, or a false positive is suspected
  • Replace performance of invasive coronary angiogram\

For symptomatic individuals, evaluate post-CABG graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed, such as in early graft failure.

For symptomatic individuals with unsuccessful conventional coronary angiography.

Re-do CABG

  • To identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.

Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels 

  • Report CPT®75574 for evaluating coronary artery anomalies.
  • Report CPT®75573 for congenital heart disease 

To evaluate the great vessels, Chest CTA (71275) can be performed instead of CCTA or in addition to CCTA

For anomalous pulmonary venous return, can add CT abdomen and pelvis with contrast (CPT®74177)

Anomalous coronary artery(ies) suspected for diagnosis or to plan treatment and less than age 40 with a history that includes one or more of the following 

  • Persistent exertional chest pain and normal stress test 
  • Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery
  • Resuscitated sudden death and contraindications for conventional coronary angiography

Unexplained new onset of heart failure

Evaluation of newly diagnosed congestive heart failure or cardiomyopathy 

  • No prior history of coronary artery disease, the ejection fraction is less than 50 percent, and low or intermediate risk on the pre-test probability assessment AND 
  • No exclusions to cardiac CT angiography
  • No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy

Ventricular tachycardia (6 beat runs or greater) if CCTA will replace conventional invasive coronary angiography

Equivocal coronary artery anatomy on conventional cardiac catheterization.

Newly diagnosed dilated cardiomyopathy

Preoperative assessment of the coronary arteries in patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography”

Vasculitis/Takayasu’s/Kawasaki’s disease

No. 176, CCTA with FFR; Last review June 2018

  1. The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography is considered medically necessary to guide decisions about the use of invasive coronary angiography in members with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic heart disease).
  2. The use of noninvasive fractional flow reserve not meeting the criteria outlined above is considered investigational.

CAC Policy 149; Last review April 2018

Computed tomography of the heart for calcium scoring (75571) is considered medically necessary based on the following criteria when there is no coronary calcium scoring in the last 5 years, no prior abnormal imaging stress test, coronary revascularization or prior catheterization or cardiac CT angiogram documenting coronary artery disease:

1. ATP* risk less than 10 percent and either of the following:

a. Father or brother with coronary heart disease diagnosed at age 55 years or less;

b. Mother or sister with coronary heart disease diagnosed at age 65 years or less

2. ATP* risk 10-19 percent AND the member has no symptoms of chest pain or shortness of breath.

Updated 1/23/19

RAD 604.007 Coronary Computed Tomography Angiography, Including Noninvasive Fractional Flow Reserve; effective 10/15/2018.

Contrast-enhanced coronary computed tomography angiography (CCTA) for evaluation of individuals without known coronary artery disease (CAD) who present with acute chest pain in the emergency room or emergency department setting may be considered medically necessary.

Contrast-enhanced CCTA for evaluation of symptomatic individuals with suspected ischemic heart disease, who meet guideline criteria for a noninvasive test in the outpatient setting may be considered medically necessary (should be performed on individuals with at least intermediate risk for coronary artery disease (10%-90% risk by standard risk prediction instruments/pre-test probability assessments). The choice of test will depend on: Interpretability of the electrocardiogram; and Ability to exercise; and Presence of comorbidities. 

Contrast-enhanced CCTA for evaluation of anomalous (native) coronary arteries in individuals in whom abnormal coronary arteries are suspected may be considered medically necessary.

CCTA, with or without contrast enhancement, as an adjunct to other testing, may be considered medically necessary for the evaluation of cardiac structure and function to:

  • Assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • Assess suspected arrhythmogenic right dysplasia, left ventricular function when cardiomyopathy is suspected or established, and right ventricular function when right ventricular dysfunction is suspected in individuals with technically limited images from echocardiography (ECG), magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE)
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE
  • Assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned.
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE.
  • Assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, pericardial effusion, or complications of cardiac surgery in patients) with technically limited images from ECG, MRI, or TEE.
  • Perform non-invasive coronary vein mapping prior to placement of a bi-ventricular pacemaker.
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation.
  • Evaluate cardiac aneurysm and pseudoaneurysm.
  • Evaluate thoracic aortic aneurysm (TAA) (such as suspected aneurysm in individuals who have not undergone computed tomography (CT) or MRI within the preceding 60 days, confirmed TAA in individuals with new or worsening symptoms, or suspected aortic dissection (with or without worsening symptoms or pre-operative planning).
  • Assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

CCTA, with or without contrast enhancement, for coronary artery evaluation is considered experimental, investigational and/or unproven for all other indications, including but not limited to:

  • Screening asymptomatic individuals for CAD.
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.
  • Evaluating individuals for any other indication not listed above, including but not limited to high or low pretest probability (low risk defined as <10% and high risk as >90%) of CAD.

CCTA performed using a multi-detector row CT scanner with less than 64-slice scanner is considered experimental, investigational and/or unproven.

Noninvasive Fractional Flow Reserve Computed Tomography

The use of noninvasive fractional flow reserve (FFR) following a positive CCTA may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of CAD (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive FFR computed tomography (FFRCT) simulation not meeting the criteria above is considered experimental, investigational and/or unproven.

If CT imaging is done of the blood vessels it is not necessarily a CCTA. A CCTA must include reconstruction post-processing of the angiographic images and interpretations, which is a key distinction between a CCTA and conventional CT. If the reconstruction post-processing is not done, it is not considered a CCTA study.

 RAD 604.009, Computed Tomography to Detect Coronary Artery Calcification, effective 12/15/2018

The use of computed tomography (CT) to detect coronary artery calcification is considered experimental, investigational and/or unproven.

Updated 1/23/2019

No current published policy.

Previous Policy CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date August 3, 2017

Medically Necessary: 

Contrast-enhanced coronary computed tomography angiography (CCTA), coronary magnetic resonance angiography (MRA), or cardiac magnetic resonance imaging (MRI) is considered medically necessary for the evaluation of suspected anomalous coronary arteries: 

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography. 

Not Medically Necessary: 

Coronary computed tomography angiography (CCTA) is considered not medically necessary for all other indications, including, but not limited to, the following: 

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met. 


RAD 00001; Last reviewed May 2018
No CAC coverage.

 

Updated 1/23/2019

No published policies found for CCT/CCTA or calcium score or FFR

 Updated 1/23/2019

Policy 06.01.34, CCTA; Last reviewed June 21, 2018

Based upon our criteria and review of the peer-reviewed literature, cardiac computed tomographic angiography (CTA), using at least a 64-slice CT scanner, is considered medically appropriate for any of the following:

Cardiac CT for structure and morphology:

  • Evaluation of native or prosthetic valve, cardiac mass, or pericardial mass and/or pericardial disease:
    • A prior cardiac CT angiogram, cardiac MRI or echocardiogram was performed for this indication and was uninterpretable.
  • Pre-procedural preparation and structural assessment of patients being considered for Transcatheter AorticValve Implantation (TAVI).
  • Coronary vein mapping:
    • Biventricular pacemaker placement is planned.
  • Pulmonary vein evaluation:
    • Radiofrequency ablation for atrial fibrillation is planned.
  • Suspected arrhythmogenic right ventricular dysplasia (ARVD) with presyncope or syncope when clinical suspicion is supported by established criteria for ARVD.
  • Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.

Cardiac CT for congenital heart disease:

  • Coronary artery anomaly evaluation:
    • A cardiac catheterization was performed and not all coronary arteries were identified.
  • Thoracic arteriovenous anomaly evaluation:
    • A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.
  • Complex congenital heart disease evaluation
    • No cardiac CT or cardiac MRI has been performed (e.g., there is a contraindication to MRI) or cardiac CT or cardiac MRI was performed one or more years ago.

Cardiac CT angiography:

  • Evaluation of known coronary artery disease (CAD) documented by prior imaging stress test, cardiac catheterization, cardiac CT angiogram, coronary revascularization, carotid stenosis or stroke, peripheral artery disease or aortic aneurysm:
    • New chest pain or shortness of breath with prior coronary artery bypass grafting to evaluated post-graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed and no exclusions to cardiac CT angiography
    • To identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.
  • For symptomatic individuals who have a very low, low or intermediate pretest probability of coronary artery disease and
    • Unable to perform either an exercise or pharmacologic imaging stress test.
    • Stress test (treadmill or imaging stress test) is normal, uninterpretable, equivocal, or a false positive is suspected.
    • Replace performance of invasive coronary angiogram.
  • Abnormal treadmill with normal imaging.
  • For symptomatic individuals with unsuccessful conventional coronary angiography.
  • Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels.
  • Anomalous coronary arter(ies) suspected for diagnosis or to plan treatment and less than age 40 with history that includes one or more of the following:
    • Persistent exertional chest pain and normal stress test
    • Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery;
    • Resuscitated sudden death and contraindications for conventional coronary angiography.
  • New onset of congestive heart failure without known coronary artery disease to assess coronary arteries; and
    • Low or intermediate risk on the pre-test probability assessment, the ejection fraction is less than 50% and no exclusion to cardiac CT angiography
  • Unexplained new onset of heart failure
  • Ventricular tachycardia (6 beat runs or greater) if CCTA will replace conventional invasive coronary angiography.
  • Equivocal coronary artery anatomy on conventional cardiac catheterization.
  • Newly diagnosed dilated cardiomyopathy.
  • Preoperative assessment of the coronary arteries in patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.
  • Vasculitis/Takayasu’s/Kawasaki’s disease.

Cardiac Trauma:

  • to detect aortic and coronary injury and can help in the evaluation of myocardial and pericardial injury.

Based upon our criteria and review of the peer-reviewed literature, cardiac computed tomographic angiography is considered investigational for all other indications.


Policy 6.01.13; Last reviewed February 2018

Based on our criteria and review of the peer reviewed literature, it is medically appropriate for patients who are candidates for CTA to have calcium scoring performed as part of a CTA procedure, since pre-test knowledge of extensive calcification of the coronary segment in question may diminish the interpretive value of a cardiac CTA.

Based on our criteria and review of the peer reviewed literature, coronary calcium scoring is considered investigational as a screening technique for asymptomatic patients.

Updated 1/19/2018

No policy currently listed.   

Former policy:  Computed Tomography Angiography for Coronary Artery Evaluation April 2018

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:

Indications where FFR-CT will not be required in conjuction 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/LV dysfunction
  • For exclusion of coronary artery disease in patients with left ventricular ejection fraction <55% and low to moderate coronary heart disease risk in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy.
    • Patients with high coronary heart disease risk should undergo cardiac catheterization.
  • Pre-operative evaluation for patients undergoing non-coronary cardiac surgery
  • Evaluation of symptomatic or asymptomatic patients at moderate coronary heart disease risk  to avoid an invasive angiogram, where all the necessary pre-operative information can be obtained using cardiac CT.
    • Procedures include open and percutaneous valvular procedures or ascending aortic surgery
  • Suspected coronary artery disease in symptomatic patients who have not had evaluation of coronary artery disease  (MPI, cardiac PET, stress echo, CCTA or cardiac catheterization) within the preceding sixty (60) days, When both of the following (1-2) apply:
    1. Patient has low or moderate coronary heart disease risk AND
    2. During testing the patient had exercise-induced chest pain, ST segment change, abnormal BP response or complex ventricular arrhythmias
  • Suspected CAD in symptomatic patients who have had equivocal MPI or SE within the past 60 days, When both of the following (1-2) apply:
    1. Patient has low or moderate coronary heart disease risk AND
    2. The imaging portion of the study is neither clearly normal nor clearly abnormal
  • Suspected CAD in symptomatic patients who have had abnormal MPI or SE within the past 60 days, When both of the following (1-2) apply:
    1. Abnormal MPI or stress echo is suspected to be false positive on the basis of low coronary heart disease risk AND
    2. 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 CAD 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 CAD 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

For the purposes of this guideline, a patient is considered to be “symptomatic” when one of the following (A-D) applies:

A.    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)

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

  • With moderate or high risk of CAD (SCORE)

C.    Other symptoms; palpitation, dizziness, lightheadedness, near syncope, nausea, vomiting, anxiety, weakness, fatigue etc.

  • With high risk of CAD (SCORE)

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

  • Diabetes mellitus; OR
  • Abdominal aortic aneurysm; 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%); OR
  • Chronic renal insufficiency or renal failure 

When Computed Tomography Angiography is not covered:

The use of CT Coronary Angiography (CCTA), with or without Fractional Flow Reserve assessed by CT (FFR-CT) is considered investigational for all other indications.

CT to Detect Coronary Artery Calcification; Last updated October 2018; Next review October 2019

No coverage for CAC – investigational

 Updated 1/23/2019

Effective July 2018

 CPT code 75574

CCTA may be considered medically necessary for the following:

  • CCTA may be appropriately used when evaluating chest pain syndromes with low to intermediate risk CAD profiles such as in emergency room or observation unit situations; or
  • CCTA may be an appropriate substitution exam for a left heart catheterization; or
  • CCTA may be appropriate prior to transcatheter aortic valve replacement (TAVR) as an alternative to coronary arteriography

The patient must meet American College of Cardiology Foundation/American Heart Association Task Force (ACCF/ASNC) Appropriateness criteria 

 

Appropriateness criteria for inappropriate indications (median score 1 – 3) or meets any ONE of the following:

  • Contraindications to beta blockers used to slow heart rate during procedure; or
  • Acute chest pain/angina; or
  • Pre-op request for non-cardiac surgery; or
  • Significant premature ventricular contractions, significant frequent atrial fibrillation, or relative contra-indication to CCTA.

 

CTA for all other clinical indications and applications is considered not medically necessary.

 

CT FFR- Procedure Codes

0501T, 0502T, 0503T, 0504T

 

FFR-CT may be considered medically necessary when ALL of the following are met:

  • Prior to CCTA, the patient was stable with a pre-test probability between 20% and 80% of significant, ischemia-producing CAD, based upon reliable calculations and the patient had at least ONE of the following scenarios:
    • A pretest probability of 20-50% (low-to-moderate) prior to CCTA and was selected for evaluation with CCTA as a non-invasive test for significant CAD. The CCTA result shows lesions of greater than or equal to 50%; or
    • A pretest probability of 51-80% (moderate or high moderate) prior to CCTA and was selected for evaluation with CCTA as a non-invasive test for significant CAD. The CCTA result shows lesions of 30-50%

FFR-CT for the following clinical scenarios are considered experimental/investigational and, therefore, non-covered. FFR-CT has not been adequately validated due to inapplicability of computational dynamics, artifacts, and/or clinical circumstances:

  • Suspicion or current presentation of an ACS unless the patient has unstable angina, MI was excluded, and invasive coronary artery (ICA) would not be recommended if FFR-CT were negative
  • Known ischemic CAD that has not been revascularized and there has been no change in the patient status or in the CCTA images
  • Recent MI within 30 days
  • Prior CBGA
  • Patients required emergent or urgent ICA, or have any evidence of ongoing or active clinical instability, including acute chest pain (sudden onset), cardiogenic shock, unstable blood pressure with systolic blood pressure less than 90 mmHg, severe CHF (New York Heart Association [NYHA] III or IV) or acute pulmonary edema Complex CHD or ventricular septal defect (VSD) with Qp/Qs greater than 1.4
  • Body Mass Index (BMI) greater than 35
  • Metallic stents in the coronary system
  • Coronary vessels with extensive or heavy calcification
  • Coronary lesions needing evaluation in which vessel diameter is less than 1.8 mm
  • Cardiac implanted electrical devices (CIEDs)
  • Prosthetic heart valves
  • Severe wall motion abnormality on CCTA results
  • Severe myocardial hypertrophy
  • High risk indicators on stress test
  • ICA within the past 90 days
  • Marginal quality of the submitted imaging data, due to motion, blooming, misalignment, arrhythmia, etc.

Note: The analysis requires a CCTA with at least a 64-slice capability and good-quality images.

 

Place of Service: Outpatient

CTA coronary arteries and fractional flow reserve CT is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

 

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Ohio (Anthem)

Updated 1/23/2019

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

 Updated 1/23/2019

Updated 1/23/19

RAD 604.007 Coronary Computed Tomography Angiography, Including Noninvasive Fractional Flow Reserve; effective 10/15/2018.

Contrast-enhanced coronary computed tomography angiography (CCTA) for evaluation of individuals without known coronary artery disease (CAD) who present with acute chest pain in the emergency room or emergency department setting may be considered medically necessary.

Contrast-enhanced CCTA for evaluation of symptomatic individuals with suspected ischemic heart disease, who meet guideline criteria for a noninvasive test in the outpatient setting may be considered medically necessary (should be performed on individuals with at least intermediate risk for coronary artery disease (10%-90% risk by standard risk prediction instruments/pre-test probability assessments). The choice of test will depend on: Interpretability of the electrocardiogram; and Ability to exercise; and Presence of comorbidities. 

Contrast-enhanced CCTA for evaluation of anomalous (native) coronary arteries in individuals in whom abnormal coronary arteries are suspected may be considered medically necessary.

CCTA, with or without contrast enhancement, as an adjunct to other testing, may be considered medically necessary for the evaluation of cardiac structure and function to:

  • Assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • Assess suspected arrhythmogenic right dysplasia, left ventricular function when cardiomyopathy is suspected or established, and right ventricular function when right ventricular dysfunction is suspected in individuals with technically limited images from echocardiography (ECG), magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE)
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE
  • Assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned.
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE.
  • Assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, pericardial effusion, or complications of cardiac surgery in patients) with technically limited images from ECG, MRI, or TEE.
  • Perform non-invasive coronary vein mapping prior to placement of a bi-ventricular pacemaker.
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation.
  • Evaluate cardiac aneurysm and pseudoaneurysm.
  • Evaluate thoracic aortic aneurysm (TAA) (such as suspected aneurysm in individuals who have not undergone computed tomography (CT) or MRI within the preceding 60 days, confirmed TAA in individuals with new or worsening symptoms, or suspected aortic dissection (with or without worsening symptoms or pre-operative planning).
  • Assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

CCTA, with or without contrast enhancement, for coronary artery evaluation is considered experimental, investigational and/or unproven for all other indications, including but not limited to:

  • Screening asymptomatic individuals for CAD.
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.
  • Evaluating individuals for any other indication not listed above, including but not limited to high or low pretest probability (low risk defined as <10% and high risk as >90%) of CAD.

CCTA performed using a multi-detector row CT scanner with less than 64-slice scanner is considered experimental, investigational and/or unproven.

Noninvasive Fractional Flow Reserve Computed Tomography

The use of noninvasive fractional flow reserve (FFR) following a positive CCTA may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of CAD (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive FFR computed tomography (FFRCT) simulation not meeting the criteria above is considered experimental, investigational and/or unproven.

If CT imaging is done of the blood vessels it is not necessarily a CCTA. A CCTA must include reconstruction post-processing of the angiographic images and interpretations, which is a key distinction between a CCTA and conventional CT. If the reconstruction post-processing is not done, it is not considered a CCTA study.

 RAD 604.009, Computed Tomography to Detect Coronary Artery Calcification, effective 12/15/2018

The use of computed tomography (CT) to detect coronary artery calcification is considered experimental, investigational and/or unproven.

 

Updated 1/23/2019

Previous:  Anomalous coronary artery mapping; ED evaluation of CAD in patients with acute chest pain without known CAD (indications as of Nov 2015; no Coronary CTA current policy published on website as of 5/16/18.  

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed October 2017.

No CAC coverage.

Updated 1/23/2019

 

 

Policy X 176-001; Cardiac: Cardiac CT, Coronary CTA, and CT for Coronary Calcium (CAC); effective January 1, 2019

Computed tomography (CT) calcium scoring for coronary artery disease (CAD) screening, please refer to Medical Policy X-173, Cardiac: General Guidelines; Table 1. 

Coronary calcium scoring as a stand- alone test is considered experimental and investigational in asymptomatic patients with any degree of CAD risk and therefore non-covered. 

Coronary computed tomography angiography (CCTA) may be considered medically necessary for the following indications:

  • Symptomatic individuals who have a low or intermediate pretest probability of CAD. 
  • Low or intermediate pre-test probability of coronary disease with persistent symptoms after a stress test;
  • Replace performance of invasive coronary angiogram in individuals with low risk of CAD (i.e. Pre-op non-coronary surgery)
  • For symptomatic individuals to evaluate post-CABG graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed, such as in early graft failure.
  • For symptomatic individuals with unsuccessful conventional coronary angiography (i.e. locate a coronary artery, graft, identify the course of an anomalous coronary artery.
  • Re-do Coronary Artery Bypass Graft (CABG) or to identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.
  • Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels.
  • Anomalous coronary artery or arteries suspected for diagnosis or to plan treatment and less than age 40 with a history that includes ONE or more of the following:
    • Persistent exertional chest pain and normal stress test; or
    • Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery; or
  • Resuscitated sudden death and contraindications for conventional coronary angiography.
  • Unexplained new onset of heart failure.
  • Evaluation of newly diagnosed congestive heart failure or cardiomyopathy.
  • No prior history of coronary artery disease, the ejection fraction is less than 50 percent, and low or intermediate risk on the pre-test probability assessment, and
    • No exclusions to cardiac CT angiography.
    • No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy
  • Ventricular tachycardia of six (6) beat runs or greater if CCTA will replace conventional invasive coronary angiography.
  • Equivocal coronary artery anatomy on conventional cardiac catheterization.
  • Newly diagnosed dilated cardiomyopathy.
  • Preoperative assessment of the coronary arteries in patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.
  • Vasculitis/Takayasu’s /Kawasaki’s disease

The following are relative contraindications for cardiac/coronary CT:

  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block)
  • Multifocal atrial tachycardia (MAT)
  • Inability to lie flat
  • Body mass index (BMI) of 40 or more.
  • Inability to obtain a heart rate less than 65 beats per minute after beta-blockers.
  • Inability to hold breath for at least eight seconds.
  • Renal Insufficiency.
  • Asymptomatic patients and routine use in the evaluation of the coronary arteries following heart transplantation.
  • CCTA should not be performed if there is extensive coronary calcification (calcium score greater than 1000).
  • Evaluation of coronary stent patency (metal artifact limits accuracy), less than three (3.0) mm.
  • Evaluation of left ventricular function following myocardial infarction or in chronic heart failure.     
  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block);
  • High pre-test probability for CAD - rather, these patients should undergo conventional coronary angiography, especially if an interventional procedure (e.g., PCI) is anticipated.
  • Identification of plaque composition and morphology.
  • Myocardial perfusion and viability studies
  • Preoperative assessment for non-cardiac, nonvascular surgery.
  • Routine follow-up of asymptomatic or stable symptoms of CAD with CCTA.
  • There is insufficient evidence to support routine use of coronary computed tomography angiography (CCTA) in the evaluation of the coronary arteries following heart transplantation.

CCTA for any other indication not listed above is considered not medically necessary.

Fractional flow reserve by computed tomography (CT) may be considered medically necessary for the following indications for FFR-CT:

  • To further asses CAD seen on a recent CCTA that is of uncertain physiologic significance.

FFR for any other indication not listed above is considered not medically necessary. 

CT of the heart for cardiac vein or pulmonary vein may be considered medically necessary for the following indications:

  • Cardiac vein identification for lead placement in patients needing left ventricular pacing
  • If echocardiogram is inconclusive for cardiac, pericardial tumor or mass, cardiac thrombus pericarditis/constrictive pericarditis or complications of cardiac surgery
  • Clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC), especially if patient has presyncope or syncope if the clinical suspicion is supported by established criteria for ARVD
  • Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.

CT of the heart for cardiac vein or pulmonary vein for any other indication not listed above is considered not medically necessary.

CT heart for congenital heart disease may be considered medically necessary for the following indications:

  • Coronary artery anomaly evaluation
  • Cardiac catheterization was performed, and not all coronary arteries were identified.
  • Thoracic arteriovenous anomaly evaluation.
  • A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.
  • Complex adult congenital heart disease evaluation.
    • No cardiac CT or cardiac MRI has been performed, and there is a contraindication to cardiac MRI
    • A cardiac CT or cardiac MRI was performed one year ago or more.

CT of the heart for Congenital Heart Disease for any other indication not listed above is considered not medically necessary

Transcatheter aortic valve replacement (TAVR):

The following tests may be considered medically necessary once a decision has been made for aortic valve replacement (TAVR) to determine if a patient is a candidate for TAVR:

  • CTA of chest, abdomen and pelvis; and
  • Cardiac CT to measure the aortic annulus
  • Coronary CTA to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.

Post TAVR:

  • TAVR follow-up may be considered medically necessary at 3 months, at one year post-procedure, and annually thereafter.

 Updated 1/23/2019

Uses NIA Magellan guidelines.

Updated 1/23/2019

Uses AIM Specialty Health guidelines for precertification or preapproval, with exception of emergency department visits and inpatient care in an observation unit.

Updated 1/23/2019

No coverage policy listed for CCTA or CAC.

Updated 1/23/2019

CAM 60143, Contrast Enhanced Computed Tomography for Coronary Artery Evaluation; Last reviewed December 2018, next review December 2019

Policy:

Computed Tomography (CT) Angiography (CTA), with or without contrast enhancement or media, utilizing 64-slice or greater multi-detector row CT (MDCT) scanner, as an adjunct to other testing MAY BE CONSIDERED MEDICALLY NECESSARY for any of the following indications:

A. Detection of coronary artery disease (CAD) in:
Symptomatic individuals (such as, chest pain syndrome as described by the American College of Cardiology [ACC]) who:

  • Have intermediate pre-test probability of CAD (as identified by the ACC guidelines); AND
  • Had a non-diagnostic stress electrocardiograph (ECG or EKG) AND
  • Have a contraindication to an exercise stress test or for whom the results are equivocal or suspected to be inaccurate, OR
  • Symptomatic individuals with unexplained chest pain or anginal equivalent symptoms (as described by the ACC) who:
    • Have intermediate pre-test probability of CAD AND
    • Had no ECG changes suggestive of ischemia or infarction; AND
    • Had negative cardiac enzymes and cardiac marker results; AND
    • Have a contraindication to an exercise stress test or for whom the results are equivocal or suspected to be inaccurate.

 B. Evaluation of cardiac structure and function:

  • To assess complex congenital heart disease, including anomalies of coronary circulation, great vessels and cardiac chambers and valves; OR
  • To assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned; OR
  • To assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from echocardiography, magnetic resonance imaging (MRI) or transesophageal echocardiography (TEE); OR
  • To assess a pericardial condition (such as, pericardial mass, constrictive pericarditis or complications of cardiac surgery in patients) with technically limited images from echocardiography, MRI or TEE; OR
  • For non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR
  • For non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR
  • For evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR
  • To assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

 Note:   Refer to the Rationale in this medical policy for guidelines issued by the ACC.

CTA, with or without contrast enhancement or media, utilizing 64-slice or greater MDCT scanner, for the evaluation of patient with acute chest pain and without known CAD in the emergency room or emergency department MAY BE CONSIDERED MEDICALLY NECESSARY.

CTA, using MDCT, to screen asymptomatic individuals for CAD or to evaluate individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing IS CONSIDERED INVESTIGATIONAL.

CTA, using MDCT, for any other indication not listed above IS CONSIDERED INVESTIGATIONAL.   

CAM 60103, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed July 2018, next review July 2019

No CAC coverage - investigational.

Updated 1/23/2019

Policy 06.01.20 – Computed Tomography Angiography of the Coronary Arteries; Last reviewed April 2016 (no longer listed on the web as of May 16, 2018).  Policy likely under revision now.

The use of CCTA is considered not medically necessary as a screening study for asymptomatic individuals because its effectiveness for this indication has not been established.

Computerized Tomographic Angiography Coronary Arteries (CCTA) may be considered medically necessary for the following indications:

Evaluation of suspected cardiac chest pain when all of the following are met:

  • No known history of coronary artery disease (CAD); and
  • Low or intermediate pre-test probability of coronary artery disease (CAD) (using Framingham risk score calculation); and
  • ECG normal/non-diagnostic for etiology of chest pain

Evaluation of suspected coronary artery disease (CAD) including those individuals with prior abnormal cardiac testing (myocardial perfusion imaging (MPI) or stress echo)

  • Individual with abnormal MPI or stress echo within the preceding 90 days suspected to be false positive on the basis of low coronary heart disease risk
  • Individual with an equivocal MPI or stress echo within the preceding 90 days who have low or intermediate coronary heart disease risk
  • For exclusion of coronary artery disease in patients with left ventricular ejection fraction <55% and intermediate coronary heart disease risk in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy.

Individuals with congestive heart failure/cardiomyopathy/left ventricular dysfunction

Evaluation for non coronary artery cardiac surgery

  • Individual with intermediate coronary heart disease risk and being evaluated for non coronary artery cardiac surgery (including valvular and ascending aortic surgery) to avoid an invasive angiogram. All the necessary pre-operative information can be obtained using cardiac CT.

Congenital coronary artery anomalies

  • For evaluation of suspected congenital anomalies of the coronary arteries

Medical Policy 06.01.06, Coronary Artery Calcium Scoring; Last reviewed July 2018

Coronary artery calcium scoring by means of computed tomography is considered investigational for all indications.

Updated 1/23/2019

Medical Policy Manual:  CCTA, Last reviewed 1/3/2019

POLICY

Coronary computed tomographic angiography is considered medically necessary if the medical appropriateness criteria are met.

MEDICAL APPROPRIATENESS

Indicated for ANY ONE of the following:

Evaluation of suspected coronary artery disease if ALL of the following are met:

  • Symptomatic individual
  • Low or intermediate risk on the pre-test probability assessment (See table below)
  • Indicated for ANY ONE of the following:
  • Persistent symptoms after stress test
  • CCTA will replace invasive coronary angiogram in individuals with low risk of CAD (i.e., pre-op non-coronary surgery)

Evaluation of post-CABG graft patency if ALL of the following are met:

  • Symptomatic individual
  • Imaging of native coronary artery anatomy is not necessary
  • Evaluation of bypass graft location for planned CABG revision
  • Symptomatic individual with unsuccessful conventional coronary angiography

Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels

  • Coronary artery anomalies suspected and ANY ONE of the following:
    • Persistent exertional chest pain and normal stress test
    • Full sibling(s) with history of sudden death syndrome
    • Full sibling(s) with documented anomalous coronary artery
    • Resuscitated sudden death and contraindications for conventional coronary angiography

New diagnosis of congestive heart failure or cardiomyopathy if ALL of the following are met:

  • No prior history of coronary artery disease
  • Ejection fraction less than 50 percent
  • Low or intermediate risk on pre-test probability assessment (see table below)
  • ABSENCE of ALL of the following since diagnosis
    • Cardiac catheterization
    • SPECT
    • Cardiac PET
    • Stress echocardiogram

Equivocal coronary artery anatomy on conventional cardiac catheterization

Preoperative assessment of coronary arteries for ANY ONE of the following surgeries:

  • Aortic dissection
  • Aortic aneurysm
  • Valvular surgery

Evaluation of coronary arteries in ANY ONE of the following conditions:

  • Unexplained new onset of heart failure
  • New diagnosis of dilated cardiomyopathy
  • Vasculitis
  • Takayasu’s Disease
  • Kawasaki’s Disease
  • Ventricular tachycardia (6 beat runs or greater)
  • Cardiac trauma

ABSENCE of ALL of the following:

  • Use in asymptomatic individuals
  • High pretest probability of CAD
  • Evaluation of coronary arteries following heart transplantation
  • Evaluation of coronary stent patency
  • Evaluation of left ventricular function following myocardial infarction or in chronic heart failure
  • Used to identify plaque composition and morphology
  • Used for myocardial perfusion and viability studies
  • Routine follow-up of asymptomatic or stable symptoms of CAD
  • BMI of 40 or greater
  • Multifocal atrial tachycardia
  • Renal insufficiency
  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature ventricular contractions or premature atrial contractions, and high grade heart block)

No coverage for CAC.  Last reviewed August 9, 2018.

FFR Policy

  • Noninvasive estimated coronary fractional flow reserve derived from coronary computed tomography angiography data (i.e. Heartflow) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
  • Noninvasive estimated coronary fractional flow reserve derived from coronary computed tomography angiography data (i.e. Heartflow) for the evaluation and/or treatment of other conditions/diseases is considered investigational. 
  • Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.

MEDICAL APPROPRIATENESS

Noninvasive estimated coronary fractional flow reserve (i.e. Heartflow) is considered medically appropriate if ALL of the following are met:

  • Results will guide decisions about the use of invasive coronary angiography
  • Individual is stable
  • Individual is at intermediate risk of coronary artery disease

Updated 1/23/2019

RAD 604.007 Coronary Computed Tomography Angiography, Including Noninvasive Fractional Flow Reserve; effective 10/15/2018.

Contrast-enhanced coronary computed tomography angiography (CCTA) for evaluation of individuals without known coronary artery disease (CAD) who present with acute chest pain in the emergency room or emergency department setting may be considered medically necessary.

Contrast-enhanced CCTA for evaluation of symptomatic individuals with suspected ischemic heart disease, who meet guideline criteria for a noninvasive test in the outpatient setting may be considered medically necessary (should be performed on individuals with at least intermediate risk for coronary artery disease (10%-90% risk by standard risk prediction instruments/pre-test probability assessments). The choice of test will depend on: Interpretability of the electrocardiogram; and Ability to exercise; and Presence of comorbidities. 

Contrast-enhanced CCTA for evaluation of anomalous (native) coronary arteries in individuals in whom abnormal coronary arteries are suspected may be considered medically necessary.

CCTA, with or without contrast enhancement, as an adjunct to other testing, may be considered medically necessary for the evaluation of cardiac structure and function to:

  • Assess complex congenital heart disease, including anomalies of coronary circulation, great vessels, and cardiac chambers and valves.
  • Assess suspected arrhythmogenic right dysplasia, left ventricular function when cardiomyopathy is suspected or established, and right ventricular function when right ventricular dysfunction is suspected in individuals with technically limited images from echocardiography (ECG), magnetic resonance imaging (MRI), or transesophageal echocardiography (TEE)
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE
  • Assess coronary arteries in individuals with new onset heart failure when ischemia is the suspected etiology and cardiac catheterization and nuclear stress test are not planned.
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE.
  • Assess a pericardial condition (such as, pericardial mass, constrictive pericarditis, pericardial effusion, or complications of cardiac surgery in patients) with technically limited images from ECG, MRI, or TEE.
  • Perform non-invasive coronary vein mapping prior to placement of a bi-ventricular pacemaker.
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation.
  • Evaluate cardiac aneurysm and pseudoaneurysm.
  • Evaluate thoracic aortic aneurysm (TAA) (such as suspected aneurysm in individuals who have not undergone computed tomography (CT) or MRI within the preceding 60 days, confirmed TAA in individuals with new or worsening symptoms, or suspected aortic dissection (with or without worsening symptoms or pre-operative planning).
  • Assess coronary arteries in asymptomatic patients scheduled for open heart surgery for valvular heart disease in lieu of invasive coronary arteriography.

CCTA, with or without contrast enhancement, for coronary artery evaluation is considered experimental, investigational and/or unproven for all other indications, including but not limited to:

  • Screening asymptomatic individuals for CAD.
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.
  • Evaluating individuals for any other indication not listed above, including but not limited to high or low pretest probability (low risk defined as <10% and high risk as >90%) of CAD.

 

CCTA performed using a multi-detector row CT scanner with less than 64-slice scanner is considered experimental, investigational and/or unproven.

Noninvasive Fractional Flow Reserve Computed Tomography

The use of noninvasive fractional flow reserve (FFR) following a positive CCTA may be considered medically necessary to guide decisions about the use of invasive coronary angiography in patients with stable chest pain at intermediate risk of CAD (i.e., suspected or presumed stable ischemic heart disease).

The use of noninvasive FFR computed tomography (FFRCT) simulation not meeting the criteria above is considered experimental, investigational and/or unproven.

If CT imaging is done of the blood vessels it is not necessarily a CCTA. A CCTA must include reconstruction post-processing of the angiographic images and interpretations, which is a key distinction between a CCTA and conventional CT. If the reconstruction post-processing is not done, it is not considered a CCTA study.

RAD 604.009, Computed Tomography to Detect Coronary Artery Calcification, effective 12/15/2018

Texas House Bill 1290, effective September 1, 2009, bars excluding coverage for cardiac computed tomography scanning measuring coronary artery calcification (including screening for atherosclerosis and abnormal artery structure and/or function) performed once every five years. Patients must be:

  • Male older than 45 years of age and younger than 76 years of age, or female older than 55 years of age and younger than 76 years of age, AND
    • Diabetic, or
    • At risk of developing coronary heart disease, based on a score derived from the Framingham Heart Study coronary prediction algorithm that is intermediate or higher.

Updated 1/23/2019

Previous:  Anomalous coronary artery mapping; ED evaluation of CAD in patients with acute chest pain without known CAD (indications as of Nov 2015; no Coronary CTA current policy published on website as of 5/16/18.  

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed October 2017, next review October 2018

No CAC coverage.

 Updated 1/23/2019

Uses AIM Specialty Health Clinical Appropriateness Guidelines: Advanced Imaging of the Heart.  Updated for release January 27, 2019

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

Updated 1/23/2019

6.01.035 Cardiac Computed Tomography and Coronary CT Angiography; last review 11/2017

The following indications for use of CT of the heart and CTA are based on the Appropriateness Criteria established by the American College of Cardiology Foundation. Computed tomography (CT) of the heart, with or without angiography, to evaluate cardiac structure and morphology for:

  • Congenital heart disorders;
  • Evaluation of pulmonary veins prior to a pulmonary vein isolation procedure for atrial fibrillation;
  • Identification of coronary veins prior to insertion of a biventricular pacemaker.
  • Computed tomography angiography (CTA) using scanners of 64 slices or greater for evaluating coronary circulation:
  • As an alternative to conventional invasive coronary angiography in patients who have had an equivocal stress ECG;
  • For the evaluation of suspected congenital anomalies of the coronary circulation;
  • For the evaluation of symptoms consistent with cardiac ischemia in patients determined to be at low to intermediate risk (Framingham criteria) for coronary artery disease;

Not recommended for screening in asymptomatic patients.

Policy 6.01.003; Computed Tomography to Detect Coronary Artery Calcification; Last reviewed February 2017; slated for review 2/21/19

The indications for the use of EBCT to detect coronary artery calcification have been updated based upon the Appropriateness Criteria established by the American College of Cardiology Foundation (2013) and include symptomatic individuals who have had an equivocal non-invasive workup where additional diagnostic information is required, but are not immediate candidates for cardiac catheterization; and asymptomatic adults at intermediate risk of a cardiac event (10% to 20% ten year risk).

 Updated 1/23/2019

No current policy listed for cardiac CT or calcium score.

Previous:  Anomalous coronary artery mapping; ED evaluation of CAD in patients with acute chest pain without known CAD (indications as of Nov 2015; no Coronary CTA current policy published on website as of 5/16/18.  

Updated 1/23/2019

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed October 2017, next review October 2018

No CAC coverage.

Policy X 176-001; Cardiac: Cardiac CT, Coronary CTA, and CT for Coronary Calcium (CAC); effective January 1, 2019

Computed tomography (CT) calcium scoring for coronary artery disease (CAD) screening, please refer to Medical Policy X-173, Cardiac: General Guidelines; Table 1. 

Coronary calcium scoring as a stand- alone test is considered experimental and investigational in asymptomatic patients with any degree of CAD risk and therefore non-covered. 

Coronary computed tomography angiography (CCTA) may be considered medically necessary for the following indications:

  • Symptomatic individuals who have a low or intermediate pretest probability of CAD. 
  • Low or intermediate pre-test probability of coronary disease with persistent symptoms after a stress test;
  • Replace performance of invasive coronary angiogram in individuals with low risk of CAD (i.e. Pre-op non-coronary surgery)
  • For symptomatic individuals to evaluate post-CABG graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed, such as in early graft failure.
  • For symptomatic individuals with unsuccessful conventional coronary angiography (i.e. locate a coronary artery, graft, identify the course of an anomalous coronary artery.
  • Re-do Coronary Artery Bypass Graft (CABG) or to identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.
  • Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels.
  • Anomalous coronary artery or arteries suspected for diagnosis or to plan treatment and less than age 40 with a history that includes ONE or more of the following:
    • Persistent exertional chest pain and normal stress test; or
    • Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery; or
  • Resuscitated sudden death and contraindications for conventional coronary angiography.
  • Unexplained new onset of heart failure.
  • Evaluation of newly diagnosed congestive heart failure or cardiomyopathy.
  • No prior history of coronary artery disease, the ejection fraction is less than 50 percent, and low or intermediate risk on the pre-test probability assessment, and
    • No exclusions to cardiac CT angiography.
    • No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy
  • Ventricular tachycardia of six (6) beat runs or greater if CCTA will replace conventional invasive coronary angiography.
  • Equivocal coronary artery anatomy on conventional cardiac catheterization.
  • Newly diagnosed dilated cardiomyopathy.
  • Preoperative assessment of the coronary arteries in patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.
  • Vasculitis/Takayasu’s /Kawasaki’s disease

The following are relative contraindications for cardiac/coronary CT:

  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block)
  • Multifocal atrial tachycardia (MAT)
  • Inability to lie flat
  • Body mass index (BMI) of 40 or more.
  • Inability to obtain a heart rate less than 65 beats per minute after beta-blockers.
  • Inability to hold breath for at least eight seconds.
  • Renal Insufficiency.
  • Asymptomatic patients and routine use in the evaluation of the coronary arteries following heart transplantation.
  • CCTA should not be performed if there is extensive coronary calcification (calcium score greater than 1000).
  • Evaluation of coronary stent patency (metal artifact limits accuracy), less than three (3.0) mm.
  • Evaluation of left ventricular function following myocardial infarction or in chronic heart failure.     
  • Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature; or ventricular contractions or premature atrial contractions, and high grade heart block);
  • High pre-test probability for CAD - rather, these patients should undergo conventional coronary angiography, especially if an interventional procedure (e.g., PCI) is anticipated.
  • Identification of plaque composition and morphology.
  • Myocardial perfusion and viability studies
  • Preoperative assessment for non-cardiac, nonvascular surgery.
  • Routine follow-up of asymptomatic or stable symptoms of CAD with CCTA.
  • There is insufficient evidence to support routine use of coronary computed tomography angiography (CCTA) in the evaluation of the coronary arteries following heart transplantation.

CCTA for any other indication not listed above is considered not medically necessary.

Fractional flow reserve by computed tomography (CT) may be considered medically necessary for the following indications for FFR-CT:

  • To further asses CAD seen on a recent CCTA that is of uncertain physiologic significance.

FFR for any other indication not listed above is considered not medically necessary. 

CT of the heart for cardiac vein or pulmonary vein may be considered medically necessary for the following indications:

  • Cardiac vein identification for lead placement in patients needing left ventricular pacing
  • If echocardiogram is inconclusive for cardiac, pericardial tumor or mass, cardiac thrombus pericarditis/constrictive pericarditis or complications of cardiac surgery
  • Clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC), especially if patient has presyncope or syncope if the clinical suspicion is supported by established criteria for ARVD
  • Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.

CT of the heart for cardiac vein or pulmonary vein for any other indication not listed above is considered not medically necessary.

CT heart for congenital heart disease may be considered medically necessary for the following indications:

  • Coronary artery anomaly evaluation
  • Cardiac catheterization was performed, and not all coronary arteries were identified.
  • Thoracic arteriovenous anomaly evaluation.
  • A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.
  • Complex adult congenital heart disease evaluation.
    • No cardiac CT or cardiac MRI has been performed, and there is a contraindication to cardiac MRI
    • A cardiac CT or cardiac MRI was performed one year ago or more.

CT of the heart for Congenital Heart Disease for any other indication not listed above is considered not medically necessary

Transcatheter aortic valve replacement (TAVR):

The following tests may be considered medically necessary once a decision has been made for aortic valve replacement (TAVR) to determine if a patient is a candidate for TAVR:

  • CTA of chest, abdomen and pelvis; and
  • Cardiac CT to measure the aortic annulus
  • Coronary CTA to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.

Post TAVR:

  • TAVR follow-up may be considered medically necessary at 3 months, at one year post-procedure, and annually thereafter.

Updated 1/23/19. As of January 2019 the coronary imaging policy was removed from Anthem Website. 

Previous policy: 

CG-MED-58, Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve Derived from CT, Coronary MRA and Cardiac MRI; Last review date: August 3, 2017

Medically Necessary

evaluation of suspected anomalous coronary arteries:

  • In pediatric individuals (age less than 18 years), either before or after conventional angiography; or 
  • In adults (age 18 and over) when conventional angiography has been unsuccessful or has provided equivocal results and the results could impact treatment.

Fractional Flow Reserve derived from Computed Tomography (FFRCT) is considered medically necessary for the evaluation of stable chest pain in individuals at intermediate risk of coronary artery disease as an alternative to invasive coronary angiography.

Fractional flow reserve derived from computed tomography (FFRCT) is considered not medically necessary for all other indications when the above criteria are not met.

Not Medically Necessary:

all other indications, including, but not limited to, the following:

  • Screening for coronary artery disease (CAD), either in asymptomatic individuals or as part of a preoperative evaluation; or 
  • Diagnosis of CAD, in individuals with acute or non-acute symptoms, or after a coronary intervention; or 
  • As a technique to evaluate cardiac function.

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  5/3/2018

The use of electron beam computed tomography (EBCT), helical CT or multi-slice spiral (also known as multi-row detector) CT (MSCT) is considered investigational and not medically necessary for the detection of coronary artery calcium, including, but not limited to, the following indications:

  • as part of a cardiac risk assessment in asymptomatic or symptomatic individuals; or
  • as a diagnostic test in individuals considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive; or
  • as a diagnostic test in symptomatic individuals; or
  • in conjunction with a coronary CT angiography (CCTA).

 Updated 1/23/2019

Policy 06-01-430 is no longer on website.   Contrast Enhanced Computed Tomography for Coronary Artery Evaluation; Last review date September 2017; next review date September 2018

Contrast-enhanced coronary computed tomography angiography for evaluation of patients without known coronary artery disease and acute chest pain in the emergency department setting is considered medically necessary.

Contrast-enhanced coronary computed tomography angiography for evaluation of patients with stable chest pain and meeting guideline criteria for a noninvasive test in the outpatient setting (see Policy Guidelines) is considered medically necessary.

Contrast-enhanced coronary computed tomography angiography for evaluation of anomalous (native) coronary arteries in patients in whom they are suspected may be considered medically necessary.

Contrast-enhanced coronary computed tomography angiography for coronary artery evaluation is considered investigational for all other indications.

Policy 06-01-003, Computed Tomography to Detect Coronary Artery Calcification; Last review date September 2017; next review date September 2018 (remains on website)

CAC is investigational.

 Updated 1/23/2019

6.01.035 Cardiac Computed Tomography and Coronary CT Angiography; last review 11/2017

The following indications for use of CT of the heart and CTA are based on the Appropriateness Criteria established by the American College of Cardiology Foundation. Computed tomography (CT) of the heart, with or without angiography, to evaluate cardiac structure and morphology for:

  • Congenital heart disorders;
  • Evaluation of pulmonary veins prior to a pulmonary vein isolation procedure for atrial fibrillation;
  • Identification of coronary veins prior to insertion of a biventricular pacemaker.

Computed tomography angiography (CTA) using scanners of 64 slices or greater for evaluating coronary circulation:

  • As an alternative to conventional invasive coronary angiography in patients who have had an equivocal stress ECG;
  • For the evaluation of suspected congenital anomalies of the coronary circulation;
  • For the evaluation of symptoms consistent with cardiac ischemia in patients determined to be at low to intermediate risk (Framingham criteria) for coronary artery disease;
  • Not recommended for screening in asymptomatic patients.

Policy 6.01.003; Computed Tomography to Detect Coronary Artery Calcification; Last reviewed February 2017; slated for review 2/21/19

The indications for the use of EBCT to detect coronary artery calcification have been updated based upon the Appropriateness Criteria established by the American College of Cardiology Foundation (2013) and include symptomatic individuals who have had an equivocal non-invasive workup where additional diagnostic information is required, but are not immediate candidates for cardiac catheterization; and asymptomatic adults at intermediate risk of a cardiac event (10% to 20% ten year risk).

 
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