EviCore Coverage Policy
Effective August 1, 2019
CD-4.1: Cardiac CT and CTA – General Information and Coding
- The high negative predictive value (98%-99%) of CCTA in ruling out significant coronary artery disease has been confirmed on multiple studies.
Cardiac Imaging Procedure Codes
| Cardiac CT
| CT, heart, without contrast, with quantitative evaluation of coronary calcium
|The code set for Cardiac CT and CCTA (CPT® 75572-CPT® 75574), include quantitative and functional assessment (for example, calcium scoring), if performed
CPT® 75571 describes a non-contrast CT of the heart with calcium scoring and should be reported only when calcium scoring is performed as a stand-alone procedure.
- Can be used to report a preliminary non-contrast scan which indicates an excessive amount of calcium such that the original scheduled study must be discontinued.
- CPT® 75571 should not be reported in conjunction with any of the contrast CT/CTA codes (CPT® 75572- CPT® 75574).
| Cardiac CT and CCTA
|CT, heart, with contrast, for evaluation of cardiac structure and morphology (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).
|CT, heart, with contrast, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).
|CTA, heart, coronary arteries and bypass grafts (when present), with contrast, including 3D image post-processing (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).
|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
|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
|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; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model
| 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; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
- 3D rendering, (CPT® 76376/CPT® 76377), should not be billed in conjunction with Cardiac CT and CCTA.
- Only one code from the set: CPT® 75572 - CPT® 75574 can be reported per encounter.
- CPT® 75574 includes evaluation of cardiac structure and morphology, when performed; therefore, additional code/s should not be assigned.
CD-4.2: CT for Coronary Calcium Scoring (CPT® 75571)
CD-4.2.1: CT Calcium Scoring for CAD Screening
Coronary calcium scoring as a standalone test is considered investigational in asymptomatic patients with any degree of CAD risk.
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:
o Must be a Texas resident.
o Must be a member of a fully-insured Texas health plan.
o Must be a man age 45 to 75 or a woman age 55 to 75.
o Must have either diabetes or a Framingham cardiac risk score of intermediate or higher.
o Must not have had a calcium scoring study or a carotid intima-media thickness study within the past 5 years.
CD-4.2.2: CT Calcium Scoring Indications
- Symptomatic individuals with a ‘very low’, or ‘low’ pretest probability of CAD*
CD-4.3: CCTA – Indications for CCTA
- Symptomatic individuals who have a ‘low’ or ‘intermediate’ pretest probability of CAD
- ‘Low’ or ‘intermediate’ pre-test probability of coronary disease with persistent symptoms after a stress test.
- Replace performance of invasive coronary angiogram in individuals with low risk of CAD (i.e. Pre-op non-coronary surgery).
For symptomatic individuals, 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.
CD-4.4: CCTA – Additional Indications
- 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 patients who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.
- Vasculitis/Takayasu’s/Kawasaki’s disease
- Cardiac Trauma: 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.
Practice Note – relative contraindications for Cardiac/Coronary CT
- Irregular heart rhythms (e.g., atrial fibrillation/flutter, frequent irregular premature ventricular contractions or premature atrial contractions, and high grade heart block)
- Multifocal Atrial Tachycardia (MAT)
- Inability to lie flat
- Body mass index of 40 or more
- Inability to obtain a heart rate less than 65 beats per minute after beta-blockers
- Inability to hold breath for at least 8 seconds
- Renal Insufficiency
- Asymptomatic patients and routine use in the evaluation of the coronary arteries following heart transplantation
- CCTA should not be performed if there is extensive coronary calcification (calcium score >1000).
- Evaluation of coronary stent patency if the vessel is less than 3.0 mm in diameter (metal artifact limits accuracy)
- Evaluation of left ventricular function following myocardial infarction or in chronic heart failure
- Patients with indeterminate echocardiogram should undergo MUGA (CPT® 78472 or CPT® 78494) or cardiac MRI.
- High pre-test probability for CAD – rather, these patients should undergo conventional coronary angiography, especially if an interventional procedure (e.g., PCI) is anticipated.
- Identification of plaque composition and morphology
- Myocardial perfusion and viability studies
- Preoperative assessment for non-cardiac, nonvascular surgery
- Routine follow-up of asymptomatic or stable symptoms of CAD with CCTA
- There is insufficient evidence to support routine use of Coronary Computed Tomography Angiography (CCTA) in the evaluation of the coronary arteries following heart transplantation.
CD-4.5: Fractional Flow Reserve by Computed Tomography
- Fractional flow reserve (FFR) is typically measured using invasive techniques. FFR can be obtained noninvasively from coronary computed tomography angiography data (FFR-CT).
- Indications for FFR-CT
- To further assess CAD seen on a recent CCTA that is of uncertain physiologic significance
CD-4.6: CT Heart – Indications
- Cardiac vein identification for lead placement in patients needing left ventricular pacing.
- Pulmonary vein isolation procedure (ablation) for atrial fibrillation
- Cardiac MRI (CPT® 75557 or CPT® 75561), chest MRV (CPT® 71555), chest CTV (CPT® 71275), or cardiac CT (CPT® 75572) can be performed to evaluate anatomy of the pulmonary veins prior to an ablation procedure performed for atrial fibrillation.
- Study may be repeated post-procedure between 3-6 months after ablation because of a 1%-2% incidence of asymptomatic pulmonary vein stenosis.
- See CD-8: Pulmonary Artery and Vein Imaging
- If echocardiogram is inconclusive for:
- Cardiac or pericardial tumor or mass
- Cardiac thrombus
- Pericarditis/constrictive pericarditis
- Complications of cardiac surgery
- Clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC), especially if patient has presyncope or syncope if the clinical suspicion is supported by established criteria for ARVD.
- Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.
- Coronary imaging is not included in the code definition for CPT® 71275.
- The AMA definition for CPT® 71275 reads: “CTA Chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and image post-processing.”
CD-4.7: CT Heart for Congenital Heart Disease
- Coronary artery anomaly evaluation
- A cardiac catheterization was performed, and not all coronary arteries were identified.
- Thoracic arteriovenous anomaly evaluation
- A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.
- Complex adult congenital heart disease evaluation
- No cardiac CT or cardiac MRI has been performed, and there is a contraindication to cardiac MRI.
- A cardiac CT or cardiac MRI was performed one year ago or more.
CD-4.8: Transcatheter Aortic Valve Replacement (TAVR)
- Once the decision has been made for aortic valve replacement, the following may be used to determine if a patient is a candidate for TAVR:
- CTA of chest (CPT® 71275), abdomen and pelvis (combination code CPT® 74174) are considered appropriate, and
- Cardiac CT (CPT® 75572) may be considered to measure the aortic annulus 2 or
- Coronary CTA (CCTA CPT® 75574) may be considered to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.
- Post TAVR:
- TAVR follow-up may be approved at 1 months, at one year post-procedure, and annually thereafter.
A baseline post-op TTE is usually performed within one week after surgery. This baseline study may also be approved as an outpatient if not performed in the hospital prior to discharge.
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