Medical Policy: 06.01.20
Original Effective Date: October 2005
Reviewed: May 2015
Revised: August 2013
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Computed Tomographic Angiography of the Coronary Arteries (CCTA) involves the use of multi-slice CT and intravenously administered contrast material to obtain detailed images of the blood vessels of the heart. It has been used as an alternative to conventional invasive coronary angiography for evaluating coronary artery disease (CAD) and coronary artery anomalies.
Studies in the peer reviewed scientific literature support the use of 64 slice system for CCTA. Studies have demonstrated that 64 slice CCTA performs with high accuracy for the diagnosis of CAD and can reduce referrals for invasive coronary angiography.
The 2010 Appropriate Use Criteria for Computed Tomographic Angiography of the Coronary Arteries (CCTA) written by the American College of Cardiology Foundation, the Society of Cardiovascular CT, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions and the Society of Cardiovascular MR includes the following:
In general, the use of CCTA for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably. Testing in high risk patients, routine repeat testing and general screening was viewed less favorably.
- Screening asymptomatic patients using CCTA, repeat CCTA in asymptomatic patients or patients with stable symptoms with prior test results, considered inappropriate.
- One area of expansion compared with the 2006 criteria involves symptomatic patients without known heart disease. CCTA was felt to be appropriate primary for situation involving a low or intermediate pretest probability of obstructive CAD.
- Detectection of CAD including those with prior abnormal cardiac testing using exercise and stress imaging
- Patient with abnormal myocardial perfusion scan (MPI) or stress echo suspected to be false positive who have low coronary heart disease risk
- Patient with equivocal myocardial perfusion scan (MPI) or stress echo who have low or moderate coronary heart disease risk
- Within heart failure with reduced left ventricular ejection fraction with low or intermediate pretest CAD probablity, CCTA considered appropriate.
- As part of a pre-operative evaluation for patients undergoing heart surgery for non-coronary indications, CCTA considered appropriate.
- Evaluation of coronary anomalies, CCTA considered appropriate.
This document represents the current understanding of the net clinical benefit of CCTA imaging with respect to the balance between benefit and risk to the patient as assessed under the American College of Cardiology Foundation (ACCF) appropriate use criteria methodology.
Framingham risk score: is a multivariable risk function that predicts 10 year risk of developing cardiovascular disease events (coronary heart disease, stroke, peripheral artery disease or heart failure). This risk score includes the following factors:
- Total and high density lipoprotein cholesterol
- Systolic blood pressure
- Diabetic status
- Cigarette Smoking
Framingham risk score key:
High: greater than 90% pre-test probability
Intermediate: between 10% and 90% pre-test probability
Low: between 5% and 10% pre-test probability
Very low: less than 5% pre-test probablity
SCORE (Systemic Coronary Risk Evaluation): predicts a 10 year risk on fatal cardiovascular disease. The SCORE incorporates the following:
- Systolic blood pressure
- Total Cholesterol
- Diabetic status
High risk: >10%
Intermediate risk: 5%-9%
Low risk: 0% - 4%
U.S. Food and Drug Administration (FDA)
Multiple manufacturers have received FDA 510(k) clearance to market CT machines. Multislice CT technology has evolved rapidly over the past several years, beginning with 4-slice scanners that were first introduced in 1998. Since then, multi-slice scanners have been approved and available for diagnostic use, with the first 64-slice system receiving FDA approval in 2004.
The use of CCTA is considered not medically necessary as a screening study for asymptomatic individuals because its effectiveness for this indication has not been established.
Computerized Tomographic Angiography Coronary Arteries (CCTA) may be considered medically necessary for the following indications:
- Evaluation of suspected cardiac chest pain when all of the following are met:
- No known history of coronary artery disease (CAD); and
- Low or intermediate pre-test probability of coronary artery disease (CAD) (using Framingham risk score calculation); and
- ECG normal/non-diagnostic for etiology of chest pain
- Evaluation of suspected coronary artery disease (CAD) including those individuals with prior abnormal cardiac testing (myocardial perfusion imaging (MPI) or stress echo)
- Individual with abnormal MPI or stress echo within the preceding 60 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).
- Individual with an equivocal MPI or stress echo within the preceding 60 days who have low or intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation).
- Individuals with congestive heart failure/cardiomyopathy/left ventricular dysfunction
- For exclusion of coronary artery disease in patients with left ventricular ejection fraction <55% and low to intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation) in whom coronary artery disease has not been excluded as the etiology of the cardiomyopathy.
- Evaluation for non coronary artery cardiac surgery
- Individual with low or intermediate coronary heart disease risk (using standard methods of risk assessment such as the SCORE risk calculation) 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
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS) level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
- Leber AW, Knez A, Becker C et al. Non-invasive intravenous coronary angiography using electron beam tomography and multi-slice computed tomography. Heart. 2003; 89(6):633-9.
- Achenbach S, Ropers D, Regenfus M et al. Noninvasive coronary angiography by magnetic resonance imaging, electron-beam computed tomography, and multi-slice computed tomography. Am J Cardiol. 2001; 88(2A):70E-73E.
- Mollet NR, Cademartiri, F, Nieman K et al. Multislice spiral computed tomography coronary angiography in patients with stable angina pectoris. J Am Coll Cardiol. 2004; 43(12):2265-70.
- Maruyama T, Yoshizumi T, Tamura R et al. Comparison of visibility and diagnostic capability of noninvasive coronary angiography by eight-slice multidetector-row computed tomography versus conventional coronary angiography. Am J Cardiol. 2004; 93(5):537-42.
- Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic Accuracy of Noninvasive Coronary Angiography Using 64-Slice Sprial Computed Tomography. J Am Coll Cardiol. 2005; 46(3)552-7.
- Hoffman MHK, Heshui S, Schmitz BL et al. Noninvasive Coronary Angiography With Multislice Computed Tomography. JAMA. 2005; 293(20):2471-8.
- Blue Cross and Blue Shield Association. Contrast-Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation. Technology Evaluation Center. Assessment Program 2005; 20(4).
- Schoenhagen P, Stillman A, Garcia M et al. Coronary artery imaging with multidetector computed tomography: A call for an evidence-based, multidisciplinary approach. Am Heart J 2006 May; 151(5):945-8.
- Fine JJ, Hopkins CB, Ruff N et al. Comparison of Accuracy of 64-slice Cardiovascular Computed Tomography with Coronary Angiography in Patients with Suspected Coronary Artery Disease. Am J Cardiol 2006 Jan; 97(2):173-4.
- Ropers D, Rixe J, Anders K et al. Usefulness of Multidetector Row Spiral Computed Tomography With 64- × 0.6-mm Collimation and 330-ms Rotation for the Noninvasive Detection of Significant Coronary Artery Stenoses. Am J Cardiol 2006 Feb; 97(3):343-348.
- Mollet NR, Cademartiri F, van Mieghem CAG et al. High-Resolution Spiral Computed Tomography Coronary Angiography in Patients referred for Diagnostic Conventional Coronary Angiography. Circulation. 2005; 112:2318-2323.
- Leschka S, Alkadhi H, Plass A et al. Accuracy of MSCT coronary angiography with 64-slice technology: a first experience. Eur Heart J. Aug 2005; 26(15):1451-3.
- Stein PD, Beemath A Kayali F et al. Multidetector Computed Tomography for the Diagnosis of Coronary Artery Disease: A Systematic Review. Am J Med. 2006 Mar; 119(3):203-16.
- Agency for Healthcare Research and Quality. Technology Assessment Program. Non-Invasive Imaging for Coronary Artery Disease. April 28, 2006.
- Blue Cross Blue Shield Association. Technology Evaluation Center. Contrast-Enhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary Artery Stenosis or for Evaluation of Acute Chest Pain. TEC Assessment Program 2006 Aug; 21(5).
- Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. J Am Coll Cardiol 2006 Oct; 48(7):1475-97.
- Jacobs JE, Boxt LM, Desjardins B et al. ACR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography. J Am Coll Radiol 2006;48(3):677-685.
- Jones CM, Athanasiou T, Dunne N et al. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Ann Thorac Surg. 2007 Jan;83(1):341-8.
- Hamon M, Biondi-Zoccai GG, Malagutti P et al. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 2006;48(9):1896-910.
- Mark DB, Berman DS, Budoff MJ et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010;55:2663-99.
- Raff GL, Chinnaiyan KM, Share DM et al. Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques. JAMA. 2009;301:2340-8.
- Kim JW, Kang EY, Yong HS et al. Incidental extracardiac findings at cardiac CT angiography: comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan. Int J Cardiovasc Imaging. 2009;25 Suppl 1:75-81.
- Bamberg F, Sommer WH, Hoffmann V et al. Meta-analysis and systematic review of the long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced coronary computed tomography angiography. J Am Coll Cardiol 2011;57(24):2426-36.
- Shaw LJ, Hausleiter J, Achenbach S et al. Coronary Computed Tomographic Angiography as a Gatekeeper to Invasive Diagnostic and Surgical Procedures: Results from the Multicenter CONFRIM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) Registry. J Am Coll Cardiol. 2012 Oct 5. pii: S0735-1097(12)04231-3. doi:10.1016/j.jacc.2012.05.062. [Epub ahead of print].
- Hausleiter J, Meyer TS, Martuscelli E et al. Image quality and radiation exposure with prospectively ECG-triggered axial scanning for coronary CT angiography: the multicenter, multivendor, randomized PROTECTION-III study. JACC Cardiovasc Imaging 2012; 5(5):484-93.
- Hoffmann U, Truong QA, Schoenfeld DA et al. Coronary CT angiography vs standard evaluation in acute chest pain. N Engl J Med 2012;367(4):299-308. doi: 10.1056/NEJMoa1201161.
- Litt HI, Gatsonis C, Snyder B et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012;366(15):1393-1403.
- Journal of the American College of Cardiology: Prognostic Value of CT Angiography for Major Adverse Cardiac Events in Patients with Acute Chest Pain from the Emergency Department: 2 Year Outcomes of the ROMICAT Trial. Img. 2011; 4:481-491, doi: 10.1016/j.jcmg.2010.12.008
- Journal of the American College of Cardiology: Prognostic Value of Cardiac Computed Tomography Angiography: A Systemic Review and Meta-Analysis: 2011;57;1237-1247, doi:10.1016/j.jacc.2010.10.011
- ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease. Available at: http://content.onlinejacc.org
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Coronary Computed Tomographic Angiography in the Evaluation of Patients with Acute Chest Pain. TEC Assessments 2011; Volume 26, Tab 9
- Jonathan Leipsic, M.D., Suhny Abbara, M.D., et. al. SCCT Guidelines for the Interpretation and Reporting of Coronary CT Angiography: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee, July 2014. Also available at http:dx.doi.org/10.1016/j.jcct.2014.07.003
Date Reason Action
September 2011 Annual review Policy renewed
November 2012 Annual review Policy renewed
January 2013 Interim review Policy revised
August 2013 Annual review Policy revised
June 2014 Annual review Policy renewed
May 2015 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
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affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.