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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

Effective March 1, 2019, uses AIM for CCT and CCTA.


https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


Policy No. 646, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed September 2018 
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 12/31/2019

No current policy listed for cardiac CT or calcium score.  Uses AIM.


https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf



Arizona

Updated 12/31/2019

Uses EviCore guidelines.


https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/cardiology-and-radiology/2019/04_evicore-cardiac-imaging_v102019_eff021519_pub101518.pdf



Arkansas

Updated 12/31/2019


Policy 1997061 -- Coronary Artery Calcium Scoring, Screening, to Predict Risk for Coronary Artery Disease; Last Review November 2019


Quantitative coronary artery calcium scoring using electron beam computed tomography or multidetector computed tomography meets primary coverage criteria of effectiveness when: 

  • Performed to determine if there is too much calcium present to proceed with CT coronary angiography OR
  • Performed as part of a pre-operative evaluation for orthotopic liver transplantation.

Policy 2005010 – Computed Tomography, Cardiac and Coronary Artery; Effective August 2019; Last Review January 2019


 Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria


 Multidetector computed tomography (MDCT) provides advanced spatial and temporal resolution of the heart and allows imaging of the major vessels of the chest, including the coronary arteries. This new technology lacks evidence-based indications, but indirect evidence, using diagnostic performance data, decision models, and an expert consensus approach validates the following current indications. Future revisions to these indications will occur as evidence based studies become available.
 Multidetector computed tomography (MDCT) and coronary computed tomographic angiography (CCTA), using 32 or more detectors and sub millimeter slices can reliably evaluate cardiac structure and morphology, native and anomalous coronary arteries and bypass grafts, congenital heart disease, left and right ventricular function, ejections fractions, and segmental wall motion. The following indications meet primary coverage criteria of effectiveness: 

  • To evaluate the coronary arteries in a patient with a low or intermediate probability of obstructive CAD, but who has an equivocal or indeterminate noninvasive diagnostic test (exercise stress test, stress echo, stress SPECT, myocardial perfusion imaging) performed to assess suspected ischemic or obstructive coronary artery disease 
  • To evaluate the coronary arteries in a patient with a low or intermediate probability of obstructive CAD, as an alternative to other testing modalities in a patient who would otherwise meet criteria for a stress echo or SPECT stress test.  
  • To evaluate suspected congenital anomalies of the coronary circulation.  
  • To evaluate acute chest pain in the emergency room in order to quickly triage patients and in order to rule out coronary artery disease as a possible cause of symptoms. 
    To evaluate the coronary and or pulmonary venous anatomy, primarily for pre surgical planning, prior to pacemaker placement or pulmonary vein catheter ablation of abnormal electrical activity for treatment of atrial fibrillation. 
  • To pre-operatively evaluate cardiac and coronary anatomy prior to non-coronary artery cardiac surgery (e.g., valve or ascending aortic surgery.  
    For noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization.  
  • For evaluation of cardiac mass (suspected tumor or thrombus) and for evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, or complications of cardiac surgery) 
  • Follow-up of coronary anatomy post cardiac transplantation 
  • Evaluation of coronary anatomy in patients with unexplained systolic heart failure (HFrEF) and low risk for obstructive coronary artery disease. 
  • Evaluation of graft patency when grafts have not been identifiable by coronary angiography 
     
    Quantitative coronary artery calcium scoring meets primary coverage criteria of effectiveness when performed to determine if there is too much calcium present to proceed with CT coronary angiography.

*NOTE: Performance of multiple non-invasive coronary artery or myocardial perfusion imaging studies on the same patient should be rarely required, and will be subject to monitoring.
 
 Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria


 The following indications do not meet member benefit primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:


 Screening: 

  •  Screening tests (examinations in men or women in the absence of signs, symptoms, or disease) are exclusions in most member benefit certificates of coverage except for coverage based on the Patient Protection and Affordable Care Act (PPACA) screening recommendations for non-grandfathered plans and those contracts with wellness benefits (which like PPACA, covers specific screening procedures). Screening with CT coronary angiography is not recommended by the USPSTF and is not covered in wellness contracts. The ACC/AHA (Taylor, 2010) recommends against screening with CT coronary angiography. 
  • Quantitative coronary artery calcium scoring (75571), (unless performed prior to CT coronary angiography to determine if there is too much calcium present to precede with CT coronary angiography.) 

Low Risk Patients:


Patients with non anginal chest pain in whom the history, physical exam, and appropriate diagnostic tests demonstrate non cardiac causes of chest pain.  

Patients with low risk of coronary artery disease based on clinical information and any other normal noninvasive coronary anatomic test within the past six months. 
 
High Risk Patients who meet the ACC/AHA Guidelines for Coronary Angiography: 


Patients with high pretest likelihood of coronary artery disease (by age, gender, and symptoms) in whom coronary angiography is indicated and or has been scheduled.  


Patients with high pretest likelihood of coronary artery disease in whom coronary angiography is indicated based on Class III or Class IV symptoms (CCSC classification of Angina Pectoris). [Class III: marked limitations of ordinary physical activity – angina occurs on walking 1-2 blocks on the level and climbing 1 flight of stairs in normal condition and at a normal pace; class IV: inability to carry on any physical activity without discomfort; anginal symptoms at rest].  


Patients with abnormal noninvasive tests which indicate high likelihood or high risk of adverse outcomes from coronary artery disease in whom coronary angiography is recommended. 

  • Patients with suspected abrupt closure or subacute stent thrombosis after percutaneous revascularization, and patients with recurrent angina or high risk criteria on noninvasive evaluation within nine months of percutaneous revascularization. In both scenarios, coronary angiography is recommended.
  • Patients who are NOT candidates for revascularization procedures because of concomitant medical issues, severe left ventricular dysfunction, or who refuse revascularization surgery. 
  • To evaluate the cause of chest pain syndrome in patients with prior bypass surgery or intracoronary stent placement. 
  • To detect coronary artery disease in asymptomatic patients who are status post revascularization procedures – (i.e., bypass grafts or intracoronary stents in asymptomatic patients).
  • For cardiac evaluation of a patient where there is a pre-test knowledge of sufficiently extensive calcification of the coronary segment in question that would diminish the interpretive value.
  • Evaluation of coronary artery disease in patients with left bundle branch block. 

 
For contracts without primary coverage criteria, the indications above listed as not meeting primary coverage criteria, are considered investigational. Investigational services are specific contract
exclusions.

Policy 2017005 -- Noninvasive Fractional Flow Reserve Using Computed Tomography Angiography; Last Review October 2019


Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria 


The use of fractional flow reserve using coronary computed tomography angiography preceding invasive coronary angiography in patients with suspected stable ischemic heart disease does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes: 
For members with contracts without primary coverage criteria, the use of fractional flow reserve using coronary computed tomography angiography preceding invasive coronary angiography in patients with suspected stable ischemic heart disease would be considered investigational and not covered for contracts without Primary Coverage Criteria.  Investigational services are an exclusion in the member benefit certificate



California (Blue Shield)

Updated 12/31/2019

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. 
 
Contrast-enhanced coronary computed tomography angiography (CCTA) may be considered medically necessary for evaluation of patients with stable chest pain and meeting guideline criteria for a noninvasive test in the outpatient setting (see Policy Guidelines).   
Contrast-enhanced coronary computed tomography angiography (CCTA) may be considered medically necessary for evaluation of anomalous (native) coronary arteries in patients in whom they are suspected.  
Contrast-enhanced coronary computed tomography angiography (CCTA) for coronary artery evaluation is considered investigational for all other indications.
Policy 6.01.03, Computed Tomography to Detect Coronary Artery Calcification; effective November 1, 2018 could not access file – appears to be website error.
No CAC coverage – investigational.


Policy 6.01.59, Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; effective August 1, 2019 accessed and updated Dec 2019


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 12/31/2019

No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020. 

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:
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 12/31/2019

No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020. 

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:

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)

No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020. 

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:

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 12/31/2019

Effective 4/1/19, uses eviCore guidelines.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/cardiology-and-radiology/2019/04_evicore-cardiac-imaging_v102019_eff021519_pub101518.pdf


Updated 12/31/19

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 (A= Appropriate (7-9), U= Uncertain (4-6)) as noted below. 


APPROPRIATE USE CRITERIA


*American College of Cardiology Foundation (ACCF) and collaborating organizations Appropriate Use Criteria: Appropriate Use Score (A = Appropriate (7-9)); Test is generally acceptable and is a reasonable approach for the indication. 


04-70450-26, Computed Tomography Heart; Last reviewed 11/15/19


Cardiac computed tomography (heart CT) meets the definition of medically necessity  for the following indications: 

Evaluation of cardiac structure and function


Adult congenital heart disease  Evaluation of anomalous thoracic arteriovenous vessels (e.g., transposition of the arteries (TGA)), when magnetic resonance imaging (MRI) cannot be performed.  Further assessment of complex adult congenital heart disease after confirmation by transthoracic echocardiogram (TTE), but TTE was inadequate for clinical management.  When TTE and/or transesophageal echocardiogram (TEE) has been or would be insufficient for clinical management, for the choice between cardiovascular magnetic resonance (CMR) and computed tomography (CT). Several aspects must be considered including radiation exposure, resolution required, sum of information required, its impact upon management, the presence of a pacemaker/implantable cardioverter defibrillator (ICD) or other implants and member claustrophobia. Sample indications include (but not limited to): o Quantification of right ventricular (RV) volumes and ejection fraction (tetralogy of Fallot, systemic RV and tricuspid regurgitation. o Evaluation of the RV outflow tract and right ventricle-to-pulmonary artery (RV-PA) conduits. o Evaluation of the entire aorta (aneurysm, dissection, intramural hematoma, Loeys-Dietz, EhlersDanlos, or confirmed genetic mutation known to predispose to aortic aneurysm and dissection. CMR or CT initially, with annual CMR (MRI) for Loeys-Dietz, Ehlers Danlos; multiple options for Marfan’s syndrome, Turner’s (see Aortic pathology section). o Evaluation of pulmonary arteries (stenosis and aneurysms) and the aorta (coarctation). o Evaluation of systemic and pulmonary veins (e.g., anomalous connection, obstruction). o Aorto-pulmonary collaterals and arteriovenous malformations. o Coronary anomalies and coronary artery disease (CAD). o Quantification of myocardial (muscle) mass.  Assessment of right ventricular morphology in arrhythmogenic right ventricular dysplasia/cardiomyopathy, based upon reason for suspicion, for example: o Nonsustained ventricular tachycardia (VT) o Syncope o Electrocardiogram (ECG) abnormality: Prolonged S wave upstroke, epsilon waves or right precordial T wave inversions (> 14 yr. old) in the absence of complete right bundle branch block (RBBB) o First degree relative with phenotype or genotype of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). 
 
Left ventricular function assessment  Evaluation of left ventricular function following acute myocardial infarction (MI) or in heart failure (HF) members, when echocardiogram (even with contrast) and radionuclide angiography/ventriculography are inadequate. 
 
Valvular assessment  Characterization of native or prosthetic valves with clinical signs or symptoms suggesting valve dysfunction, when TTE, TEE and fluoroscopy have been inadequate (e.g. bioprosthetic valve thrombus post transcatheter or surgical valve replacement).  Evaluation of the calcium score of the aortic valve in symptomatic members with severe calcific aortic stenosis by calculated valve area (≤ 1.0 square cm), low flow (stroke volume ≤ 35mL/square M) with low gradient (mean < 40 mm Hg or Doppler < 4 M/sec), and ejection fraction < 50%, when low dose dobutamine shows no flow (contractile) reserve (failure to increase stroke volume > 20%), to assist with the determination of the severity of the aortic stenosis. Severe (in Aggatston units): >1,200 women, >2,000 men).  Evaluation of the calcium score of the aortic valve in symptomatic members with severe calcific aortic stenosis by calculated valve area (≤ 1.0 square cm), low flow (stroke volume ≤ 35 ml/square M) with low gradient (< 40 mm Hg or Doppler < 4 M/sec), and preserved ejection fraction ≥ 50%, to assist with the determination of the severity of the aortic stenosis. Severe (in Aggatston units): >1,200 women, >2,000 men).  Evaluation of the calcium score of the aortic valve in symptomatic members with severe calcific aortic stenosis by calculated valve area (≤ 1.0 square cm and index ≤ 0.6 square cm/square M), normal flow (stroke volume ≥ 35 mL/square M) with low gradient (mean < 40 mm Hg or Doppler < 4 M/sec), and preserved ejection fraction ≥ 50%, to assist with the determination of the severity of the aortic stenosis. Severe (in Aggatston units): >1,200 women, >2,000 men).   Evaluation of RV systolic function, including systolic and diastolic volumes, in severe tricuspid regurgitation (TR), when TTE images are inadequate and CMR is not readily available.  Evaluation of suspected infective endocarditis with moderate to high pretest probability (i.e. staph bacteremia, fungemia, prosthetic heart valve, intracardiac device) when transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) have been inadequate.  Evaluation of morphology/anatomy in the setting of suspected paravalular infections when the anatomy cannot be clearly delineated by transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TTE).  Members with bicuspid aortic valve and aortic dilation > 4.0 cm require annual imaging with CT, MRI, or echocardiogram. Echocardiogram is required when it can evaluate the full extent of pathology under surveillance. This would increase to biannual (twice-yearly) imaging in the event of any one of the additional conditions: diameter > 4.5 cm, rapid rate of change 0.5 cm/yr. or a family history of a first degree relative with aortic dissection.  Initial imaging with first 6-month reevaluation for rate of expansion is appropriate.  Evaluation of intra and extracardiac structures  Evaluation of cardiac mass (suspected tumor or thrombus, including valvular mass or vegetation), when imaging with TTE and TEE have been inadequate.  Evaluation of pericardial anatomy, when transthoracic echocardiogram (TTE) and/or transesophageal echocardiogram (TEE) are inadequate or for better tissue characterization of a mass and detection of metastasis, if malignancy is suspected.  
 
Electrophysiologic procedure planning  Evaluation of pulmonary venous anatomy prior to radiofrequency ablation of atrial fibrillation and for follow up when needed for evaluation of pulmonary vein stenosis.  Non-invasive coronary vein mapping prior to placement of biventricular pacing leads.  

Transcatheter structural intervention planning  Assessment of the aortic annular dimensions, aortic root, and aortic valve, in planning for transcatheter aortic valve replacement (TAVR).  When transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) cannot provide adequate imaging, CT imaging can be used for planning: robotic mitral valve repair, atrial septal defect closure, left atrial appendage closure, ventricular septal defect closure, endovascular grafts, and percutaneous pulmonic valve implantation.  Evaluation for suitability of TMVR, transcatheter mitral annuloplasty, and transcatheter mitral paravalvular mitral valve leak (PVML) closure, alone or in addition to TEE.

Aortic pathology

Echocardiogram is required when it can evaluate the full extent of pathology under surveillance. 

CT, MR or echocardiogram can be used for screening and follow up with CT and MR preferred for imaging beyond the proximal ascending thoracic aorta (see table below, Aortic Diameters Ascending and Descending by Gender, Age and BSA: Upper limits of normal (top normal sizes)). o Screening first degree relatives of members with a history of thoracic aortic aneurysm (defined as > 50% above top normal) or dissection or an associated high-risk mutation for thoracic aneurysm in common. o Screening second degree relative of a member with thoracic aortic aneurysm (defined as > 50% above top normal), when the first degree relative has aortic dilation, aneurysm, or dissection. o Six months follow up after initial finding of a dilated thoracic aorta, for assessment of rate of change. o Annual follow up of enlarged thoracic aorta that is above top normal for age, gender, and size up to 4.4 cm. o Biannual (twice/yr.) follow up of enlarged aortic root > 4.5 cm (> 4.5 cm for bicuspid aortic valve) or showing growth rate > 0.5 cm/year.


Members with Marfan require annual imaging with CT, MRI (avoids radiation, especially when frequent evaluation required) or echo when it can evaluate the full extent of pathology, with increase to biannual (twice-yearly) when diameter reaches 4.5 cm or when expansions is > 0.5.  Members with Turner’s syndrome should undergo imaging (CT, MRI (avoids radiation, especially when frequent evaluation required) or echo (when it can evaluate the full extent of pathology) of the heart and aorta for evidence of dilatation of the ascending thoracic aorta, and with normal imaging and no risk factors for aortic dissection, repeat imaging should be performed every 5-10 years or if otherwise indicated. If the aorta is enlarged, appropriate follow-up imaging should be done according to size, as noted above. With a bicuspid aortic valve, the recommendation below applies.  Members with bicuspid aortic valve and aortic dilation > 4.0 cm require annual imaging with CT, MRI, or echo. (Echo is required when is can evaluate the full extent of pathology under surveillance.) This would increase to biannual (twice-yearly) imaging in the event of any one of the additional conditions: diameter > 4.5 cm, rapid rate of change 0.5 cm/yr. or a family history of a first degree relative with aortic dissection. Initial imaging with first 6-month re-evaluation for rate of expansion is appropriate.  CMR can be used for the diagnosis and surveillance of aortitis.   Any interval increase > 3 mm on echo should be validated by CT or CMR.   When higher resolution measurement is required for determining an indication or surgery, CT appear slightly better.  Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ascending aorta.  Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months post un-operated dissection or intramural hematoma, penetrating atherosclerotic aortic ulcer, and if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion.  Postoperative surveillance recommendations are taken from the 2010 ACC Thoracic Aortic Disease Guideline.


04-78000-22; Noninvasive Fractional Flow Reserve Measurement; 6/15/19


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 – investigational.


Updated 12/31/19. As of January 2019


No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf
NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 
RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19
Investigational and Not Medically Necessary:
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 12/31/19

Uses Magellan Hawaii (formally known as NIA) guidelines.  April 2019.
https://www1.radmd.com/media/825304/2019-nia-clinical-guidelines.pdf 


Idaho (Blue Cross)

Updated 12/31/19

Policy 6.01.59, Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve; Effective 5/16/2019


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; Last Review and Effective September 19, 2019


No CAC coverage – investigational.



Idaho (Regence)

Updated 12/31/19

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed January 2019; next review October 2019 (no update as of Dec 2019)


No CAC coverage – considered investigational.
No policy published for CCTA.

Updated 12/31/19

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 (refer to NOTE 1 below).


NOTE 1: A noninvasive test 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:


1. Interpretability of the electrocardiogram; and


2. Ability to exercise; and


3. Presence of comorbidities.


(Class I recommendation from the 2012 American College of Cardiology Foundation/American Heart Association Task Force on use of noninvasive testing in patients with suspected stable ischemic heart disease. See the Description section for definitions, guidelines, and pre-test probability assessment identified by the Task Force.)


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; OR


• 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); OR


• Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE; OR


• 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


• Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE; OR


• 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; OR


• Perform non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR


• Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR


Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR


• Evaluate cardiac aneurysm and pseudoaneurysm; OR


• 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); OR


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; OR


• Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing; OR


• 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 (refer to NOTE 1 above) 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.

NOTE 2: 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.

NOTE 3: For any CT to detect coronary artery calcification, see policy RAD604.009

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.


EXCEPTION: TEXAS contracts only: 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

  1. 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 1/23/19. 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 12/31/2019

Cardiac Computed Tomography; Revised November 26, 2019

Cardiac CT for evaluating cardiac structure and morphology may be medically necessary for the following indications: 1. Evaluation of the pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation 2. Evaluation of persons needing biventricular pacemakers to accurately identify the coronary veins for lead placement 3. Suspected or known Marfan's syndrome 4. Evaluation of sinus venosum atrial-septal defect 5. Kawasaki's disease 6. Anomalous pulmonary venous drainage 7. Pulmonary outflow tract obstruction 8. Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart disease 9. Evaluation of other complex congenital heart diseases.


Contrast Enhanced CCTA for Coronary Artery Evaluation; Last revised November 5, 2019


A. Contrast-enhanced coronary computed tomography angiography for evaluation of patients with symptoms of stable ischemic heart disease and meeting guideline criteria (see Policy Guidelines) for a noninvasive test in the outpatient setting is considered medically necessary.  
 B. Contrast-enhanced coronary computed tomography angiography for evaluation of patients without known coronary artery disease and acute chest pain in the emergency room/emergency department setting is considered medically necessary. 
 C. 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.  
 D. 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 August 14, 2019


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).  
B. 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 12/31/2019

 No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 

RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:

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 12/31/2019

Policy No. 00153, Contrast Enhanced Computed Tomography for Coronary Artery Evaluation; Effective 6/1/2019


For exclusion of CAD  in  patients with left ventricular  ejection fraction <  55%  and low or intermediate  coronary  heart disease  risk (using  standard methods of risk assessment such as Framingham  or the  American College  of Cardiology  [ACC]  criteria) in patients whom CAD


 has not been excluded as the etiology of the  cardiomyopathy; OR 

  • 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); OR 
  • For suspected coronary  artery  disease  in patients who have  had abnormal exercise electrocardiogram (EKG)  test (performed without imaging) within the past 60 days 
     when BOTH of the following  apply 
       Patient is  symptomatic (See Policy Guidelines); AND 
       During  testing  the  patient  had  exercise-induced  chest  pain,  ST  segment  change, 
     abnormal  blood  pressure  (BP)   response  or complex ventricular  arrhythmias; OR 
     •  For suspected coronary  artery  disease  in patients who have  had equivocal  myocardial perfusion  imaging  (MPI)  or  stress  echocardiography  (SE)  within the  past  60 days  when BOTH of the following  apply 
       Patient is  symptomatic (See Policy Guidelines); AND 
       The  imaging  portion of the  study  is neither clearly  normal nor clearly  abnormal; 
     OR 
  • For 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 (See Policy Guidelines); AND 
       The imaging portion of the study is abnormal; OR 
  • For suspected coronary  artery disease in symptomatic patients who have abnormal resting 
     EKG in the following situation (See Policy Guidelines): 
       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; OR
    Suspected coronary  artery  disease  in symptomatic  patients who have  not  had recent CAD 
     evaluation in the following situation (See Policy  Guidelines): 
       When no CAD  imaging  evaluation (MPI, cardiac  positron emission tomography 
     [PET], stress echo, CCTA  or coronary angiography) has  been performed within the 
     preceding sixty (60) days. 
    All other uses are investigational.

    Policy No. 00031, Computed Tomography to Detect Coronary Artery Calcification; Policy Retired effective November 10, 2019


No CAC coverage – investigational


Policy No. 00537, CCTA with Selective Noninvasive Fractional Flow Reserve; effective September 28, 2019


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 who meet coverage criteria for CCTA (as noted in medical policy 00153) to be eligible for coverage.**.
 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 12/31/2019

Medical Policy Manual 
Policy 149 Radiology
Adult Cardiac Imaging; CT Section CD 4
 
CAC – necessary if:  

  • 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 [And one of the following]
  • ATP* risk <10 percent and [One of the following] 
    • Father or brother with coronary heart disease diagnosed at age 55 or less
    • Mother or sister with coronary heart disease diagnosed at age 65 or less
  • ATP* risk 10-19 percent AND 
    • No symptoms of chest pain or shortness of breath

    Medicare policies consider that there is insufficient evidence based data to support the performance of Coronary Calcium Scoring. 

    Texas Heart Attack Preventive Screening Law (HR 1290) mandates that insurers in Texas cover either a calcium scoring study (CPT® 75571 or HCPCS S8092) or a carotid intima-media thickness study (ultrasound—Category III code 0126T) every five years for certain populations. To qualify, the following must apply: 

     

    • Must be a Texas resident.
    • Must be a member of a fully-insured Texas health plan.
    • Must be a man age 45 to 75 or a woman age 55 to 75.
    • Must have either diabetes or a Framingham cardiac risk score of intermediate or higher.
    • Must not have had a calcium scoring study or a carotid intima-media thickness study within the past 5 years.


      CT necessary for Symptomatic individuals who have a ‘low’ or ‘intermediate’ pretest probability of CAD*, see Table 1 in CD-1.1: General Issues – Cardiac: 

    ‘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, 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

    CTA necessary for:


    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 (CPT® 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
      • Prior nondiagnostic coronary angiography in determining the course of the anomalous coronary artery in relation to the great vessels, origin of a coronary artery or bypass graft location. 


      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 members 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: Chest CTA (CPT® 71275) and CCTA (CPT® 75574) are useful in detecting aortic and coronary injury and can help in the evaluation of myocardial and pericardial injury see CD-10.1: Cardiac Trauma – Imaging 


Updated 12/31/19

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 (refer to NOTE 1 below).


NOTE 1: A noninvasive test 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:


1. Interpretability of the electrocardiogram; and


2. Ability to exercise; and


3. Presence of comorbidities.


(Class I recommendation from the 2012 American College of Cardiology Foundation/American Heart Association Task Force on use of noninvasive testing in patients with suspected stable ischemic heart disease. See the Description section for definitions, guidelines, and pre-test probability assessment identified by the Task Force.)


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; OR
  • 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); OR
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE; OR
  • 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
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE; OR
  • 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; OR
  • Perform non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR
  • Evaluate cardiac aneurysm and pseudoaneurysm; OR
  • 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); OR
  • 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; OR
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing; OR
  • 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 (refer to NOTE 1 above) 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.


NOTE 2: 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.
NOTE 3: For any CT to detect coronary artery calcification, see policy RAD604.009

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.


EXCEPTION: TEXAS contracts only: 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
3. 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 12/31/2019

No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:
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 12/31/2019

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

 

 Updated 12/31/2019

Policy 06.01.34, CCTA; Last reviewed August 22, 2019

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: A. Cardiac CT for structure and morphology: 1. Evaluation of native or prosthetic valve, cardiac mass, or pericardial mass and/or pericardial disease: a. A prior cardiac CT angiogram, cardiac MRI or echocardiogram was performed for this indication and was uninterpretable. 2. Pre-procedural preparation and structural assessment of patients being considered for Transcatheter AorticValve Implantation (TAVI): a. Post TAVR at one month and one year post-procedure and annually thereafter. 3. Coronary vein mapping: a. Biventricular pacemaker placement is planned. 4.  Pulmonary vein evaluation: a. Radiofrequency ablation for atrial fibrillation is planned. 5. Suspected arrhythmogenic right ventricular dysplasia (ARVD) with presyncope or syncope when clinical suspicion is supported by established criteria for ARVD. 6. Recurrent laryngeal nerve palsy due to cardiac chamber enlargement. B. Cardiac CT for congenital heart disease: 1. Coronary artery anomaly evaluation: a. A cardiac catheterization was performed and not all coronary arteries were identified. 2. Thoracic arteriovenous anomaly evaluation: a. A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease. 3. Complex congenital heart disease evaluation: a. 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. C. Cardiac CT angiography: 1. 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: a. 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; or

b. To identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned. 2. For symptomatic individuals who have a very low, low or intermediate pretest probability of coronary artery disease and: a. Unable to perform either an exercise or pharmacologic imaging stress test. b. Stress test (treadmill or imaging stress test) is normal, uninterpretable, equivocal, or a false positive is suspected. c. Replace performance of invasive coronary angiogram. 3. Abnormal treadmill with normal imaging. 4. For symptomatic individuals with unsuccessful conventional coronary angiography. 5. Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels. 6. 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: a. Persistent exertional chest pain and normal stress test: or b. Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery; or c. Resuscitated sudden death and contraindications for conventional coronary angiography; or d. Prior nondiagnostic coronary angiography in determining the course of anomalous coronary artery in relation to the great vessels, origin of a coronary artery or bypass graft location. 7. New onset of congestive heart failure without known coronary artery disease to assess coronary arteries; and a. Low or intermediate risk on the pre-test probability assessment, the ejection fraction is less than 50% and no exclusion to cardiac CT angiography; and b. No cardiac catheterization, SPECT, cardiac PET, or stress echocardiograms has been performed since the diagnosis of congestive heart failure or cardiomyopathy. 8. Unexplained new onset of heart failure. 9. Ventricular tachycardia (6 beat runs or greater) if CCTA will replace conventional invasive coronary angiography. 10. Equivocal coronary artery anatomy on conventional cardiac catheterization. 11. Newly diagnosed dilated cardiomyopathy. 12. 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. 13. Vasculitis/Takayasu’s/Kawasaki’s disease. D.  Cardiac Trauma: to detect aortic and coronary injury and can help in the evaluation of myocardial and pericardial injury. II. 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. III. 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 3/22/2019

Based on our criteria and review of the peer reviewed literature, coronary calcium scoring is considered investigational as a screening technique for asymptomatic patients.  II. Based on our criteria and review of the peer reviewed literature, it is medically appropriate for patients who are candidates for cardiac computed tomographic angiography (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 cardiac CTA


Updated 12/31/2019

No policy published on CCT or CCTA.  Uses AIM criteria.

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf

CT to Detect Coronary Artery Calcification; Last updated October 2019; Next review October 2020
No coverage for CAC – investigational


 Updated 12/31/2019


CTA Coronary Arteries and FFR CT; effective July 2018

https://www.bcbsndmedicalpolicy.com/documents/cta-coronary-arteries-fractional-flow-reserve-ct/

Updated 12/31/2019

No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:
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 12/31/2019

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 (refer to NOTE 1 below).


NOTE 1: A noninvasive test 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:


1. Interpretability of the electrocardiogram; and


2. Ability to exercise; and


3. Presence of comorbidities.


(Class I recommendation from the 2012 American College of Cardiology Foundation/American Heart Association Task Force on use of noninvasive testing in patients with suspected stable ischemic heart disease. See the Description section for definitions, guidelines, and pre-test probability assessment identified by the Task Force.)

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; OR
  • 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); OR
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE; OR
  • 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
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE; OR
  • 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; OR
  • Perform non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR
  • Evaluate cardiac aneurysm and pseudoaneurysm; OR
  • 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); OR
  • 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; OR
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing; OR
  • 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 (refer to NOTE 1 above) 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.


NOTE 2: 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.


NOTE 3: For any CT to detect coronary artery calcification, see policy RAD604.009

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.


EXCEPTION: TEXAS contracts only: 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


4. 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 12/31/2019

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed January 2019; next review October 2019 (no update as of Dec 2019)

No CAC coverage – considered investigational.


No policy published for CCTA.

Updated 12/31/2019

 Uses eviCore guidelines.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/cardiology-and-radiology/2019/04_evicore-cardiac-imaging_v102019_eff021519_pub101518.pdf

 Updated 12/31/2019

No published policy for CCT/CCTA or calcium score.  Uses NIA/Magellan.


https://www1.radmd.com/media/825304/2019-nia-clinical-guidelines.pdf

 

Updated 12/31/2019

No published policy for CCT/CCTA or calcium score.  Uses AIM Specialty Health.

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf

Updated 12/31/2019

No coverage policy listed for CCTA or CAC.

Updated 12/31/2019

CAM 712 CT Heart, to be reviewed December 2020.

INDICATIONS FOR HEART COMPUTED TOMOGRAPHY (CT) are considered MEDICALLY NECESSARY for the following indications:


Evaluation of Cardiac Structure and Function
Congenital Heart Disease

 

  • When transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE) have been or are expected to be insufficient for clinical management in complex congenital heart disease, cardiac magnetic resonance imaging (CMR) or computed tomography (CT) may be required. For the choice between CMR and CT, several aspects must be considered, including radiation exposure, resolution required, sum of information required, impact upon management, the presence of a pacemaker/implantable cardioverter defibrillator (ICD) or other implants, and patient claustrophobia. Indications include:
    • Evaluation of anomalous thoracic arteriovenous vessels, such as transposition of the great arteries, when magnetic resonance imaging (MRI) cannot be performed
    • Quantification of right ventricle (RV) volumes and ejection fraction (Tetralogy of Fallot, systemic RV, and tricuspid regurgitation) [CMR better than CT, if available]
    • Evaluation of the RV outflow tract and RV-PA conduits (CMR or CT)
    • Evaluation of pulmonary arteries (stenosis and aneurysms) and the aorta (coarctation) (CMR or CT)
    • Evaluation of systemic and pulmonary veins (anomalous connection, obstruction) (CMR or CT)
    • Aorto-pulmonary collaterals and arteriovenous malformations (either, but CT is superior to CMR for spatial resolution)
    • Coronary anomalies and CAD (indication for CCTA, better than CMR)
    • Quantification of myocardial (muscle) mass (CMR or CT)
    • Assessment of right ventricular morphology in suspected arrhythmogenic right ventricular cardiomyopathy, based upon other findings such as:
      • Nonsustained VT
      • Unexplained syncope
      • ECG abnormalities
      • First-degree relative with positive genotype of ARVC (either, but CMR is superior to CT)

Left Ventricular Function Assessment

  • Left ventricular systolic dysfunction in the absence of severe valvular disease, when TTE and MUGA are inadequate


Valvular Heart Disease

  • Characterization of native or prosthetic valves with clinical signs or symptoms suggesting valve dysfunction, when TTE, TEE, and/or fluoroscopy have been inadequate 
  • Evaluation of RV function in severe TR, including systolic and diastolic volumes, when TTE images are inadequate and CMR is not readily available
  • Pulmonary hypertension in the absence of severe valvular disease
    Evaluation of suspected infective endocarditis with moderate to high pretest probability (i.e., staph bacteremia, fungemia, prosthetic heart valve, or intracardiac device), when TTE and TEE have been inadequate.
  • Evaluation of suspected paravalvular infections when the anatomy cannot be clearly delineated by TTE and TEE
  • Patients with bicuspid aortic valve and aortic dilation > 4.0 cm require annual imaging with CT, MRI, or echocardiography. Echocardiography is required when it can evaluate the full extent of pathology under surveillance. This would increase to biannual (twice-yearly) imaging in the event of any one of these additional conditions: diameter > 4.5 cm, rapid rate of change 0.5 cm/yr, or a family history of a first-degree relative with aortic dissection. Initial imaging with first 6 month re-evaluation for rate of expansion is appropriate.

Evaluation of Intra- and Extra-cardiac Structures 

  • Evaluation of cardiac mass, suspected tumor or thrombus, or cardiac source of emboli, when imaging with TTE and TEE have been inadequate 
  • Re-evaluation of prior findings for interval change (i.e., reduction or resolution of atrial thrombus after anticoagulation), when a change in therapy is anticipated  

Evaluation of pericardial anatomy, when TTE and/or TEE are inadequate or for better tissue characterization of a mass and detection of metastasis [CMR superior for physiologic assessment (constrictive versus restrictive) and tissue characterization, CT superior for calcium assessment]


Electrophysiologic Procedure Planning

  • Evaluation of pulmonary venous anatomy prior to radiofrequency ablation of atrial fibrillation and for follow-up when needed for evaluation of pulmonary vein stenosis 
  • Non-invasive coronary vein mapping prior to placement of biventricular pacing leads 
  • Evaluation of suspected post-ablation pulmonary vein stenosis  

Transcatheter Structural Intervention Planning

  •  Assessment of the aortic annular dimensions, aortic root, and aortic valve, in planning for transcatheter aortic valve replacement (TAVR) 
  • When TTE and TEE cannot provide adequate imaging, CT imaging can be used for planning: robotic mitral valve repair, atrial septal defect closure, left atrial appendage closure, ventricular septal defect closure, endovascular grafts, and percutaneous pulmonic valve implantation 
  • Evaluation for suitability of transcatheter mitral valve procedures, alone or in addition to TEE


Aortic Pathology


TTE is recommended when it can evaluate the full extent of pathology under surveillance.

  • CT, MR, or echo can be used for screening and follow-up, with CT and MR preferred for imaging beyond the proximal ascending thoracic aorta (see table below for top normal sizes) in the following scenarios: 
    • Evaluation of dilated aortic sinuses or ascending aorta identified by TTE
    • Suspected acute aortic pathology, such as dissection
    • Re-evaluation of known aortic dilation or aortic dissection with a change in clinical status or cardiac examination or when findings would alter management 
    • Screening first-degree relatives of individuals with a history of thoracic aortic aneurysm (defined as ≥ 50% above top normal) or dissection, or an associated high-risk mutation for thoracic aneurysm in common
    • Screening second-degree relative of a patient with thoracic aortic aneurysm (defined as ≥ 50% above top
      normal), when the first-degree relative has aortic dilation, aneurysm, or dissection
    • Six-month follow-up after initial finding of a dilated thoracic aorta, for assessment of rate of change
    • Annual follow-up of enlarged thoracic aorta that is above top normal for age, gender, and size up to 4.4 cm
    • Biannual (twice/yr) follow-up of enlarged aortic root ≥ 4.5 cm (> 4.5 cm for bicuspid aortic valve) or showing
      growth rate ≥ 0.5 cm/year

    CAM 60143, Contrast Enhanced Computed Tomography for Coronary Artery Evaluation; Last reviewed December 2019; Next Review December 2020


    CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY (CCTA) is considered MEDICALLY NECESSARY for the following indications.


    Evaluation in Suspected Coronary Artery Disease (CAD):

  • Intermediate or high pretest probability patients in whom stress echo cannot be performed (see Background section)
  • Low pretest probability patients in whom either exercise stress electrocardiogram (ECG) (uninterpretable) or stress echo cannot be performed (see Background section)
  • Appropriate exercise ECG stress test with low Duke Treadmill Score (≥ 5) and continued symptoms concerning for CAD
  • Exercise ECG stress test with intermediate Duke Treadmill Score (- 10 to + 4).
  • Equivocal, borderline, or discordant stress imaging evaluationwith continued symptoms concerning for CAD
  • Repeat testing in patient with new or worsening symptoms since prior normal stress imaging (Taylor 2010, Wolk 2013)
  • Newly diagnosed clinical systolic heart failure (ejection fraction [EF] < 50%) without recent CAD evaluation, in the presence of angina or an anginal equivalent
  • Reduced EF (EF ≤ 40%) as an alternative to invasive coronary arteriography
  • Before valve surgery or transcatheter intervention in patients with low or intermediate pretest probability of CAD as an alternative to coronary angiography
  • To establish the etiology of mitral regurgitation (Nishimura 2014)
  • Evaluation of coronary anomaly or aneurysm (CMR favored in young patients)
  • Evaluation of coronary artery bypass grafts, to assess
  • Patency and location, when invasive coronary arteriography was either nondiagnostic or would like to be avoided
  • Location prior to cardiac or other chest surgery  

For all policies all other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.


CAM 60103, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed July 2019, next review July 2020


No CAC coverage - investigational.

Updated 12/31/2019

No current published policy for CT/CTA


Medical Policy 06.01.06, Coronary Artery Calcium Scoring; Last reviewed July 2019

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

Updated 12/31/2019

Medical Policy Manual:  CCTA; Last review 10/10/2019


POLICY

  • Coronary computed tomographic angiography is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
  • Coronary computed tomographic angiography for all other indications is considered investigational.

MEDICAL APPROPRIATENESS

  • Coronary computed tomographic angiography (CCTA) is considered medically appropriate if ALL of the following are met:
    • 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 Review 7/11/2019


          FFR Policy – Last review 1/12/2018

  • 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 12/31/2019

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 (refer to NOTE 1 below).


NOTE 1: A noninvasive test 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:


1. Interpretability of the electrocardiogram; and


2. Ability to exercise; and


3. Presence of comorbidities.


(Class I recommendation from the 2012 American College of Cardiology Foundation/American Heart Association Task Force on use of noninvasive testing in patients with suspected stable ischemic heart disease. See the Description section for definitions, guidelines, and pre-test probability assessment identified by the Task Force.)
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; OR
  • 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); OR
  • Assess suspected or established dysfunction of prosthetic cardiac valves in individuals with technically limited images from ECG, MRI, or TEE; OR
    • 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
  • Assess a cardiac mass (suspected tumor or thrombus) in individuals with technically limited images from ECG, MRI, or TEE; OR
    • 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; OR
  • Perform non-invasive coronary vein mapping prior to placement of a biventricular pacemaker; OR
  • Perform non-invasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization; OR
  • Evaluate pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation; OR
  • Evaluate cardiac aneurysm and pseudoaneurysm; OR
  • 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); OR
  • 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; OR
  • Evaluating asymptomatic individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing; OR
  • 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 (refer to NOTE 1 above) 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.


NOTE 2: 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.


NOTE 3: For any CT to detect coronary artery calcification, see policy RAD604.009



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.


EXCEPTION: TEXAS contracts only: 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


5. Diabetic, or 


6. 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 12/31/2019

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed January 2019; next review October 2019 (no update as of Dec 2019)

No CAC coverage – considered investigational.


No policy published for CCTA.

 Updated 12/31/2019

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

https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf 

Updated 12/31/19.

 No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:
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 12/31/2019

6.01.035 Cardiac Computed Tomography and Coronary CT Angiography; Revised 12/16/2019.  Next review 12/6/2021.

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 3/25/19

Considered medically necessary.

A search of the peer-reviewed literature was performed for the period of September 2012 through October 2014.  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).

Update 2019: A search of the peer-reviewed literature was performed for the period of February 2017 through January 2019.  Findings in the recent literature do not change the conclusions on the medically necessary indications for the use of electron beam computed tomography (EBCT) to detect calcium deposits in coronary arteries.


 Updated 12/31/2019

No current policy listed for cardiac CT or calcium score.  Uses AIM.

Updated 12/31/2019

Policy No. 6, Computed Tomography to Detect Coronary Artery Calcification; Last reviewed January 2019; next review October 2019 (no update as of Dec 2019)

 No CAC coverage – considered investigational.

No policy published for CCTA.

Updated 12/31/2019

 

Uses eviCore guidelines.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/cardiology-and-radiology/2019/04_evicore-cardiac-imaging_v102019_eff021519_pub101518.pdf


Updated 12/31/19.

 

 No medical policy published for CCTA.  Uses AIM Guidelines.  New version of AIM cardiac imaging guidelines to take effect 2020.  https://aimspecialtyhealth.com/wp-content/uploads/2019/11/AIM_Guidelines_Cardiac_Imaging.pdf


NOTE: Anthem, Inc. Medical Policies have been developed for specific services and supersede any AIM clinical appropriateness guideline relevant to that service. 


RAD 00001, Computed Tomography to Detect Coronary Artery Calcification; Last review date:  3/21/19


Investigational and Not Medically Necessary:
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 12/31/2019

Policy 06-01-003, Computed Tomography to Detect Coronary Artery Calcification; Last review date September 2019; next review date September 2020


CAC is investigational.

 Updated 12/31/2019

6.01.035 Cardiac Computed Tomography and Coronary CT Angiography; Revised 12/16/2019.  Next review 12/6/2021.

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 3/25/19

Considered medically necessary.

A search of the peer-reviewed literature was performed for the period of September 2012 through October 2014.  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).

Update 2019: A search of the peer-reviewed literature was performed for the period of February 2017 through January 2019.  Findings in the recent literature do not change the conclusions on the medically necessary indications for the use of electron beam computed tomography (EBCT) to detect calcium deposits in coronary arteries.