BlueCross and BlueShield of Montana Medical Policy/Codes
Computed Tomography (CT) Angiography (CTA) Using Advanced CT Systems
Chapter: Radiology
Current Effective Date: December 27, 2013
Original Effective Date: May 01, 2006
Publish Date: December 27, 2013
Revised Dates: May 3, 2012; December 10, 2013
Description

Computed Tomography (CT) Angiography (CTA) is a non-invasive technique used to examine blood flow by delineating the vascular anatomy. Common applications are vascular assessment of the heart, lung vasculature, major neck vessels, brain circulation, as well as the aorta, abdominal and pelvic vasculature, including liver or kidneys. Intravenously administered contrast substance is injected during image acquisition, outlining the blood vessels on the x-rays. The specific application of CTA in the coronary arteries required overcoming several technical challenges to obtain high-quality diagnostic images.

  1. Very short image acquisition times are necessary to avoid blurring artifacts from the rapid motion of the beating heart. In some cases, premedication with beta-blocking agents is used to slow the heart rate below 60 to 65 beats per minute, for adequate scanning.
  2. Rapid scanning is essential for image acquisition during patient breath-holding.
  3. Electrocardiograph (ECG or EKG) triggering or retrospective gating is necessary to obtain images during the optimal reconstruction window and minimize motion. Certain uncontrolled arrhythmias, such as atrial fibrillation, pose a problem with gating and may preclude adequate coronary artery CTA examination.Severe coronary artery calcification from extensive atherosclerotic plaque (Agatston coronary artery calcium score over 1,000) may create blooming artifact, which accentuates the attenuation and overestimates the degree of stenosis, with partial obscuration of the vascular lumen. Very thin sections (less than one millimeter [mm]) are important to provide adequate spatial resolution and high quality three-dimensional (3-D) reconstruction images.

A CTA to examine any blood vessel of the body includes reconstruction post-processing of angiographic images and interpretation. When using CTA to examine coronary arteries, the post-processing may be undertaken using multiplanar reconstruction (MPR) of cross-sectional images to display the coronary arteries. Curved MPR and thin-slab maximum intensity projections (MIPs) provide an overview of the coronary arteries, and volume-rendering techniques (VRT) provide a 3-D anatomical display of the exterior of the heart. Quantification of coronary stenosis may be difficult given current techniques, although improvements in image reconstruction algorithms, such as vessel tracking are being developed. If the reconstruction post-processing is not done, it is not a CTA study.

A standard axial CT is a cross-sectional collection of x-ray images or “slices” of anatomy. These images are obtained from fan-shaped beam of x-rays which pass through the patient’s body to an arc-shaped row of detectors (a pie-shape wedge). The patient passes through a tube known as a gantry, having the x-ray source mounted on one side and an arc-shaped detector mounted on the opposite side. he detector records about 1,000 or more images during each rotation of the gantry. The computer processes the results, displaying them as a two-dimensional (2-D) picture.

Newer CT units with faster computer systems and software are emerging, such as:

  • Electron-Beam Computed Tomography (EBCT) - EBCT utilizes advanced high-speed digital technology with rapid scan times to freeze moving organs (stop-action pictures of the heart between heartbeats) and to reduce or eliminate distortion/blurring usually created by motion. The scan needs only one-tenth of a second to make an x-ray image of the heart. This rapid scanning is made possible by an electron beam/gun rather than the mechanical movement of an x-ray tube as required by conventional CT scanners. It can be utilized with or without an intravenous (IV) injection of radiographic contrast medium.
  • Spiral (Helical) Computed Tomography (Spiral CT, Helical CT) - Spiral CT or Helical CT also creates images or slices at greater speeds by rotating, in a spiral path, a standard x-ray tube around the patient such that data are gathered in a continuous spiral or helix rather than by sequential acquisition of individual slices.
  • Multiple-Detector (Multi-Detector) Row Helical Computed Tomography (MDCT) or Multiple-Slice (Multi-Slice) Computed Tomography (MSCT) – MDCT is a higher resolution and higher speed version of Spiral CT. MDCT captures multiple slices for each detector, in which a MDCT may have 4, 8, 16, 32, 40, or 64 detectors (creating numerous pie-shape wedges). The CT machines are equipped with an array of x-ray detectors that can simultaneously image multiple sections of the patient during a rapid volumetric image acquisition.

The same CTA process can be applied to numerous other vascular structures in the body, such as cerebral arteries in the brain, as well as the renal arteries of the kidneys and pulmonary arteries of the lungs, without the requirement of slowing the heart rate down.

Evaluation of obstructive coronary artery disease (CAD) involves quantifying the degree of luminal narrowing, to determine whether hemodynamically significant stenosis is present. Symptomatic lesions with greater than 50 % to 75 % diameter stenosis are generally considered significant and often result in revascularization procedures when viable myocardium (heart muscle) is present. It has been suggested that CTA may be helpful to rule out the presence of CAD and to avoid conventional invasive coronary angiography (CA) in patients with very low clinical likelihood of significant CAD. There is an increasing interest in exploring the role of nonsignificant plaques (those associated with less than 50 % stenosis) because it is theorized some of these plaques (vulnerable plaque) are unstable may undergo rupture or erosion, leading to acute myocardial infarction. Cross-sectional angiographic imaging may visualize the presence and composition of these plaques and quantify the plaque burden better than conventional angiography, which only visualizes the vascular lumen (open space of the tubular blood vessel). However, it is not yet well established how this information would be used to guide patient management.

The information sought from angiography after coronary artery bypass graft (CABG) surgery may depend on the length of time since initial surgery. CABG occlusion may occur during the early post-operative period; whereas, over the long term, recurrence of obstructive CAD may occur in the CABG, which requires a similar evaluation as a CAD in the original or native blood vessels.

Congenital coronary arterial anomalies leading to clinically significant problems are rare lesions. Symptomatic manifestations may include ischemia (localized tissue anemia) or syncope (faintness, dizziness, or loss of consciousness). The clinical presentation of coronary arterial anomalies is hard to distinguish from other more common causes of cardiac disease. However, it is an important diagnosis to exclude, particularly in young patients who present with unexplained symptoms, such as syncope.

CTA has several limitations or concerns.

  1. The presence of dense arterial calcification may result in blooming artifact and an intracoronary stent can produce significant beam-hardening artifact producing an unsatisfactory study.
  2. The presence of an uncontrolled rapid heart rate or arrhythmia hinders the ability to obtain diagnostically satisfactory images.
  3. The evaluation of the distal coronary arteries is generally more difficult than visualization of the proximal and mid-segment coronary arteries due to greater cardiac motion and the smaller caliber of coronary vessels in distal locations.
  4. The exposure to radiation doses associated with CTA, compare the following radiation doses associated with other CT technologies:
    • Four-row MDCT with 1 mm sections delivers an effective radiation dose of approximately 7.1 to 11.9 millisievert (mSv) (range has been reported from 5 to 13 mSv) and 16-row MDCT with 0.75 mm sections delivers approximately 8.8 mSv. The 64-row MDCT delivers an effective radiation dose of approximately 11 to 22 mSv; with ECG-controlled modulation, the effective radiation dose can be reduced to approximately 7 to 11 mSv.
    • EBCT delivers the lowest dose of approximately 0.7 to 1.1 mSv (some research shows range from 1.1 to 1.5 mSv) with 3 mm sections.
    • Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) delivers an effective radiation dose of approximately 15 to 20 mSv.
    • Conventional invasive CA delivers approximately 4 to 8 mSv.
    • For natural background radiation, the average yearly effective dose is 2.5 mSv.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Computed Tomography (CT) Angiography (CTA), with or without contrast enhancement or media, utilizing 64-slice or greater multi-detector row CT (MDCT) scanner, as an adjunct to other testing may be considered medically necessary for any of the following indications:

A. Detection of coronary artery disease (CAD) in:

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

B. Evaluation of cardiac structure and function:

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

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

CTA, with or without contrast enhancement or media, utilizing 64-slice or greater MDCT scanner, for the evaluation of patient with acute chest pain and without known CAD in the emergency room or emergency department may be considered medically necessary.

MDCT with less than 64-slice scanner is considered experimental, investigational and unproven.

CTA, using MDCT, to screen asymptomatic individuals for CAD or to evaluate individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing is considered experimental, investigational and unproven.

CTA, using MDCT, for any other indication not listed above is considered experimental, investigational and unproven.

Policy Guidelines

CPT code 71250, 71260, 71270 describe CT of thorax without contrast, with contrast or without contrast followed by contrast administration. These codes are not applicable for documenting CTA.

Using CPT code 71275 for CTA of the chest is not the appropriate code for heart or coronary vessel testing. This code reflects the use for screening or diagnostic testing to rule out pulmonary emboli or mediastinal masses.

The correct CPT codes are 75571, 75572, 75573, and 75574 CTA of heart and/or coronary arteries.

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

Rationale

This policy was originally based on a literature search through February 2006 and updated with a May 2005 Blue Cross Blue Shield Association Technology Evaluation Center (TEC) Assessment. The objective of the TEC Assessment was to evaluate the clinical effectiveness of contrast-enhanced cardiac computed tomography (CT) angiography (CTA) using either electron-beam computed tomography (EBCT) or multiple-detector (multi-detector) row helical computed tomography (MDCT) as a noninvasive alternative to invasive cardiac angiography (CA), particularly in patients with a low probability of significant coronary artery stenosis. Evaluation of the coronary artery anatomy and morphology is the most frequent use of cardiac CTA and was the primary focus of the TEC Assessment. Cardiac CTA may also provide evaluation of the cardiac chambers, myocardial wall thickness, and functional evaluation of the heart including perfusion patterns of enhancement and estimation of ejection fraction, but this use was not addressed in this Assessment.

Screening for coronary artery disease (CAD): No eligible studies were identified using CTA as a screening test for CAD in asymptomatic subjects or among subjects planned for major noncardiac surgery.

Diagnosis of CAD (Acute): One small study examined the use of CTA in 22 hospitalized patients with non-ST elevation acute coronary syndromes who were scheduled for CA. CTA yielded evaluable images of vessel segments >2 mm in diameter in 98% of cases and achieved 94% sensitivity, 96% specificity, 99% negative predictive value (NPV), and 77% positive predictive value (PPV) for stenosis >50% compared with conventional CA. The study also suggested that if CTA had been used for initial evaluation in place of CA, three patients (14%) with no significant CAD might have been spared CA. The very high NPV in this small study is of interest, but this would need to be confirmed in additional large prospective studies.

Diagnosis of CAD (Non-acute): There are 14 studies (total n=723) reporting the diagnostic performance characteristics of CTA for evaluation of non-acute, symptomatic patients with known or suspected CAD who are scheduled for invasive CA. Most studies were prospective, double-blinded, and used conventional invasive CA as the reference standard. The results for CTA were variable with technical success in achieving evaluable vessels between 79% and 93% for MDCT and 77% and 89% for EBCT. It is important to consider the patient as the unit of analysis, and one study that provided this information found that 74% of patients had all vessels evaluable on CTA. This implies that approximately one fourth of subjects undergoing MDCT may have at least some limitation in the visualization of the coronary arteries.

Within the 11 studies using MDCT (total n=622), four studies (total n=289) reported patient-based analyses, CTA achieved 85%–100% sensitivity, 78%–86% specificity, 81%–97% PPV, and 75%–100% NPV. It is important to recognize that the higher sensitivity estimates in these ranges addressed only segments >2mm in diameter. A larger number of studies provide vessel- or vessel segment-based analyses reporting sensitivity ranging from 63%–95%, specificity 86%–98%, PPV 64%–87%, and NPV 96%–99%. This NPV is frequently reported as being high enough to exclude the diagnosis of significant stenoses; however, this analysis addresses vessels/segments and decisions to avoid invasive CA and are not based on a per vessel analysis. Furthermore, the prevalence of significantly stenotic vessels is only 10%–37%, which will make the NPV appear higher than if CTA were analyzed at the patient level where there is a higher prevalence of significant CAD with all vessels summed together. These vessel/segment-based analyses may be useful in determining treatment decisions about single vessels, but are not the most useful analyses when making treatment decisions about the patient as a whole. Thus, to exclude the diagnosis of CAD and avoid the need for invasive CA, the NPV for the patient based on all the coronary arteries is the relevant information.

Among the studies using EBCT (total n=101), all three studies report diagnostic performance based on vessels or segments with a prevalence of stenotic vessels/segments of 15%–21%. Sensitivity range was 70%–77%, specificity was 91%–95%, NPV was 95%, and PPV was 70%–73%.

Diagnosis after CABG:  One prospective study examined the use of MDCT in 48 patients who were scheduled for CA after CABG. After excluding three technical failures, the authors report technical success in visualizing 100% of bypass grafts and 74% of distal anastomoses. Sensitivity, specificity, PPV and NPV for graft occlusion were 96%, 95%, 81%, and 99%, respectively. However, this study provides no information about patient symptoms or how evidence of graft occlusion would affect management.

Diagnosis of CAD after stent:  Two small studies (one MDCT and one EBCT) have examined the feasibility of using CTA for evaluation shortly after stent placement and found 74% to 87% of stents evaluable. However, these small studies were very limited in reporting, did not examine subjects with suspicion of clinically recurrent CAD, and one did not used double-blinded assessment.

Delineation of coronary artery anomaly:  Two small studies including a total of 29 subjects, who were all selected for study based on a known or suspected coronary artery anomaly, suggest that CTA may provide a better evaluation of anomalous arterial anatomy than conventional CA. However, both studies were retrospective and neither prospectively evaluated the diagnostic performance of CTA in evaluating unknown consecutive clinical cases.

Delineation of coronary artery anatomy prior to cardiovascular procedure:  One small study reports that it is feasible to delineate coronary venous anatomy based on simultaneous coronary arterial and venous enhancement on EBCT. Another recently published study examined the predictive value of CTA in 45 patients with chronic total coronary occlusions who were scheduled for percutaneous revascularization. Results of multivariable logistic regression were reported, but performance characteristics for CTA such as sensitivity, specificity, PPV, and NPV for procedural failure are not reported. Thus, these results are not sufficient to determine the effect of using CTA on management and health outcomes.

In summary, the available evidence does not provide sufficient information to permit conclusions on the effect of CTA on health outcomes. Available studies are limited by small sample size, single-center design, possible overlap of patient populations with duplicate reporting, failure to enroll clinically relevant patient population, variable technical success rates for CTA, inconsistent analysis of diagnostic performance characteristics, reporting of diagnostic performance limited to evaluable segments, failure to report diagnostic performance per patient, and, most importantly, the inability to translate diagnostic performance of CTA to expected effects on management and health outcomes.

Special comment from American Heart Association (AHA) (2000):  "The increased predictive value of EBCT of coronary arteries relative to traditional risk factor assessment is not yet completely defined. EBCT is not a substitute for cardiac catheterization."

June 2007 Update

In 1999, the American College of Cardiology (ACC) and AHA released a joint scientific statement describing the assessment of cardiovascular or coronary heart disease (CHD) risk to categorize patients for selection of appropriate interventions (available in the ACC website http://www.acc.org ). The statement defines CHD, as derived from the Framingham Heart Study, to include angina pectoris, unstable angina or coronary insufficiency, and unrecognized myocardial infarction (MI) (defined by EKG). The ACC/AHA scientific statement further states, “The first step in determining the patient’s risk is to calculate the number of Framingham points for each risk factor”, by using the Framingham Global Risk Assessment Scoring:

Risk Factor

Risk Points

Men

Women

Age by year:

 

Less than 34

-1

9

35 – 39

0

-4

40 – 44

1

0

45 – 49

2

3

50 – 54

3

6

55 – 59

4

7

60 – 64

5

8

65 – 69

6

8

70 - 74

7

8

Total Cholesterol, mg/dL*:

 

Less than 160

-3

-2

169 – 199

0

0

200 – 239

1

1

240 – 279

2

2

Greater than or equal to 280

3

3

HDL cholesterol, mg/dL*:

 

Less than 35

2

5

35 – 44

1

2

45 – 49

0

1

50 – 59

0

0

Greater than or equal to 60

-2

-3

Systolic blood pressure, mm Hg**:

 

Less than 120

0

-3

120 – 129

0

0

130 – 139

1

1

140 – 159

2

2

Greater than 160

3

3

Diabetes:

 

No

0

0

Yes

2

4

Smoker:

 

No

0

0

Yes

2

2

*          mg dL = milligrams/deciliter

**        mm Hg = millimeter of mercury as it relates to a unit of pressure equal to 0.001316 atmosphere

Adding Up the Points

Age:

 

Cholesterol:

 

HDL – C:

 

Blood Pressure:

 

Diabetes:

 

Smoker:

 

Total Points:

 

Additionally the 1999 ACC/AHA scientific statement explained the following tables as demonstrating the relative and absolute risk estimates for CHD in men and women as determined for Framingham scoring, including this explanation for table information, “Relative risk estimates for each age range are compared with baseline risk conferred by age alone (in the absence of other major risk factors).” Additionally described was, “Average risk refers to that observed in the Framingham population. Absolute risk estimates are given in the two right hand columns. Absolute risk is expressed as the percentage likelihood of developing CHD per decade. Total CHD risk equates to all forms of clinical CHD, whereas hard CHD includes clinical evidence of MI and coronary death. Hard CHD estimates are approximated from published Framingham data.”

In the following grids, the intermediate risk estimates (classified as moderately above average risk) will be identified as bolded and high risk as underlined. Following the last grid (for women), the keys for these symbols “*”, “#”, “++”, and “**” will be defined.

MEN

Age

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

 

 

Low Risk Level*

(2%)

(3%)

(3%)

(4%)

(5%)

(7%)

(8%)

(10%)

(13%)

Absolute Risk

Absolute Risk ++

Points#

 

 

 

 

 

 

 

 

 

Total CHD++

Hard CHD**

0

1.0

 

 

 

 

 

 

 

 

2%

2%

1

1.5

1.0

1.0

 

 

 

 

 

 

3%

2%

2

2.0

1.3

1.3

1.0

 

 

 

 

 

4%

3%

3

2.5

1.7

1.7

1.3

1.0

 

 

 

 

5%

4%

4

3.5

2.3

2.3

1.8

1.4

1.0

 

 

 

7%

5%

5

4.0

2.6

2.6

2.0

1.6

1.1

1.0

 

 

8%

6%

6

5.0

3.3

3.3

2.5

2.0

1.4

1.3

1.0

 

10%

7%

7

6.5

4.3

4.3

3.3

2.6

1.9

1.6

1.3

1.0

13%

9%

8

8.0

5.3

5.3

4.0

3.2

2.3

2.0

1.6

1.2

16%

13%

9

10.0

6.7

6.7

5.0

4.0

2.9

2.5

2.0

1.5

20%

16%

10

12.5

8.3

8.3

6.3

5.0

3.6

3.1

2.5

1.9

25%

20%

11

15.5

10.3

10.3

7.8

6.1

4.4

3.9

3.1

2.3

31%

25%

12

18.5

12.3

12.3

9.3

7.4

5.2

4.6

3.7

2.8

37%

30%

13

22.5

15.0

15.0

11.3

9.0

6.4

5.6

4.5

3.5

45%

35%

>14

26.5

>17.7

>17.7

>13.3

>10.6

>7.6

>6.6

>5.3

>4.1

>53%

>45%

WOMEN

Age

40-44

45-49

50-54

55-59

60-64

65-69

70-74

 

 

Low Risk Level*

(2%)

(3%)

(5%)

(7%)

(8%)

(8%)

(8%)

Absolute Risk

Absolute Risk ++

Points#

 

 

 

 

 

 

 

Total CHD++

Hard CHD**

0

1.0

 

 

 

 

 

 

2%

1%

1

1.0

 

 

 

 

 

 

2%

1%

2

1.5

1.0

 

 

 

 

 

3%

2%

3

1.5

1.0

 

 

 

 

 

3%

2%

4

2.0

1.3

 

 

 

 

 

4%

2%

5

2.0

1.3

 

 

 

 

 

4%

2%

6

2.5

1.7

1.0

 

 

 

 

5%

2%

7

3.0

2.0

1.2

 

 

 

 

6%

3%

8

3.5

2.3

1.4

1.0

 

 

 

7%

3%

9

4.0

2.7

1.6

1.1

1.0

1.0

1.0

8%

3%

10

5.0

3.3

2.0

1.4

1.3

1.3

1.3

10%

4%

11

5.5

3.7

2.2

1.6

1.4

1.4

1.4

11%

7%

12

6.5

4.3

2.6

1.9

1.6

1.6

1.6

13%

8%

13

7.5

5.0

3.0

2.1

1.9

1.9

1.9

15%

11%

14

9.0

6.0

3.6

2.6

2.3

2.3

2.3

18%

13%

15

10.0

6.7

4.0

2.9

2.5

2.5

2.5

20%

15%

16

12.0

8.0

4.8

3.4

3.0

3.0

3.0

24%

18%

>17

>13.5

>9.0

>5.4

>3.9

5.4

5.4

5.4

>27%

>20%

Symbols Key:

*          Low absolute risk level = 10-year risk for CHD end points for the person the same age, blood pressure less than 120 mm Hg systolic and less than 80 mm Hg diastolic, serum total cholesterol - 160 to 199 mg/dL, LDL-C - 100 to 129 mg/dL (LDL = low-density lipoprotein), HDL-C - greater or equal to 45 mg/dL in men and greater or equal to 55 mg/dL in women, nonsmoker, and no diabetes mellitus. Percentages show 10-year absolute risks for total CHD endpoints.

#          Points = number of points estimated from the Framingham Global Risk Assessment Scoring.

++        10-year absolute risk for total CHD end points estimated from the Framingham data corresponding to the Framingham (Global Risk Assessment Scoring) points.

**        10-year absolute risk for hard CHD end points approximated from the Framingham data   corresponding to the Framingham (Global Rish Assessment Scoring) points.

A further literature review was done from March 2006 through May 2007, which included Appropriateness Criteria for CTA published in the Journal of the ACC. In 2006, Hendel and colleagues, along with key specialty and subspecialty societies compiled a grouping of indications and applications for CTA as few clinical practice guidelines currently existed. This consensus approach to evaluate the test performance of CTA by purpose and within specific clinical scenarios is formally known as “A Report of the American College of Cardiology Foundation (ACCF) Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology (ACR), Society of Cardiovascular Computed Tomography (SCCT), Society for Cardiovascular Magnetic Resonance (SCMR), American Society of Nuclear Cardiology (ASNC), North American Society for Cardiac Imaging (NASCI), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Interventional Radiology (SIR) 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging”.

Hendel and colleagues, as the ACC Appropriateness Criteria technical panel, concluded their review of indications were not exhaustive, but could provide usefulness to clinicians the ability to use the ratings as a supportive decision or educational tool when ordering a test or providing a referral to another qualified physician. Each indication was ranked through two rounds in addition to intervening discussion leading to consensus. The category of “uncertain” was the definition of those indications that “either critical data were lacking or significant differences of opinion exist among the panel members regarding the value of the method for that particular indication. These indications include using CTA to screen asymptomatic individuals for CAD or to evaluate individuals with cardiac risk factors in lieu of cardiac evaluation and standard non-invasive cardiac testing.

The ACC technical panel presented several opinions indicating CTA as appropriate to evaluate the suspicion of anomalous coronary arteries when conventional angiography was non-diagnostic, to detect CAD in selected clinical settings in symptomatic patients with a intermediate probability of CAD when EKG was uninterpretable, or in the evaluation of chest pain syndrome with uninterpretable or equivocal stress tests. In addition, CTA was considered appropriate to evaluate coronary arteries etiology in patients with new onset heart failure.  

In 2006, the AHA released a scientific assessment of CTA utilization referenced the 2006 ACC Appropriateness Criteria. The AHA confirmed, “CT coronary angiography may develop into a clinically useful tool. CT coronary angiography is reasonable for the assessment of obstructive disease in symptomatic patients (Class IIa, Level of Evidence: B). Several small studies have assessed the value of EBCT and MDCT for detecting restenosis after stent placement. At this time, however, imaging of patients to follow up stent placement cannot be recommended (Class III, Level of Evidence: C).” 

Furthermore, AHA does not recommend CTA, sited as Class III, Level of Evidence C, for the assessment or tracking of atherosclerosis or stenosis over time, in addition to not recommending CTA in asymptomatic persons for the assessment of occult CAD or scanning in the use to assess cardiovascular risk or presence of obstructive disease.

In addition, AHA affirmed, “MDCT-64 is the current standard for coronary CTA”, which is line with the rapid evolution. Utilization of EBCT technology to assess coronary indications is limited due to lower power and larger slice imaging. However, EBCT does allow for a lower dose of radiation when compared to MDCT (1.1 to 1.5 mSv with EBCT to MDCT at 5 to 13 mSv), yet EBCT does not provide the improved image quality required for CTA evaluation. As CT technology is evolving, it is projected by the scientific literature that the radiation dose estimates will likely decrease as modification of the hardware and the scanning protocols proceed.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

87.42, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07

ICD-10 Codes

I25.10, I25.110, I25.111, I25.118, I25.119, I25.3, I25.41, I25.42, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.790, I25.791, I25.798, I25.799, I25.810, I25.82, I25.83, I25.84, I25.89, I25.9, BW03ZZZ

Procedural Codes: 71275, 75571, 75572, 75573, 75574, S8092
References
  1. Achenbach, S., et al. Coronary angiography by electron beam tomography. Herz (1996 April) 21(2):118-26.
  2. Achenbach, S., et al. Value of electron-beam computed tomography for the noninvasive detection of high-grade coronary-artery stenoses and occlusions. New England Journal of Medicine  (1998 December 31) 339(27):1964-71.
  3. Morise, A.P. Comparison of the diamond-forrester method and a new score to estimate the pretest probability of coronary disease before exercise testing. American Heart Journal (1999) 138(4):740-5.
  4. Grundy, S.M., Pasternak, R., et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Journal of American College of Cardiology (1999) 34:1348-59.
  5. AHA – Computer Imaging/Tomography. The American Heart Association (2000). Available at http://www.americanheart.org (accessed - 2006 March 10).
  6. ACC/AHA – Gibbon, R.J., ACC/AHA 2002 Guideline Update for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) (2002 July). Available at http://www.acc.org or http://www.americanheart.org (accessed – 2007 February 20).
  7. ACC/AHA – Gibbon, R.J., ACC/AHA 2002 Guideline Update for Management of Patients With Chronic Stable Angina. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients With Chronic Stable Angina) (2002 October). Available at http://www.acc.org or http://www.americanheart.org (accessed – 2007 February 20).
  8. Nieman, K., Rensing, B.J., et al. Usefulness of multislice computed tomography for detecting obstructive coronary artery disease. American Journal of Cardiology (2002 April 15) 89(8):913-8.
  9. Romagnoli, A., Nisini, A., et al. Multidetector row CT coronary angiography:  Technique and preliminary experience. Radiologica Medica (Torino) (2002 May – June) 103(5-6):443-55.
  10. Gaylord, G.M. Computed tomographic and magnetic resonance coronary angiography:  Are you ready?  Radiology Management (2002 July – August) 24(4):16-20.
  11. Becker, C.R., Knez, A., et al. Detection of coronary artery stenoses with multislice helical CT angiography. Journal of Computer Assisted Tomography (2002 September – October) 26(5):750-5.
  12. Treede, H., Becker, C., et al. Multidetector computed tomography (MDCT) in coronary surgery: First experiences with a new tool for diagnosis of coronary artery disease. Annals of Thoracic Surgery (2002 October) 74(4):S1398-402.
  13. Nieman, K., Cademartiri, F., et al. Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation (2002 October 15) 106(16):2051-4.
  14. Computed Tomography to Detect Coronary Artery Calcification. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Radiology 6.01.03.
  15. Gerber, T.C., Kuzo, R.S., et al. Image quality in a standardized algorithm for minimally invasive coronary angiography with multislice spiral computed tomography. Journal of Computer Assisted Tomography (2003 January – February) 27(1):62-9.
  16. Perez-Lugones, A., Schwartzman, P.R., et al. Three-dimensional reconstruction of pulmonary veins in patients with atrial fibrillation and controls: morphological characteristics of different veins. Pacing and Clinical Electrophysiology (2003 January) 26(Part 1):8-15.
  17. Scharf, C., Sneider, M., et al. Anatomy of the pulmonary veins in patients with atrial fibrillation and effects of segmental ostial ablation analyzed by computed tomography. Journal of Cardiovascular Electrophysiology (2003 February) 14(2):150-5.
  18. JACC – Schwartzman, D., Lacomis, J., et al. Characterization of Left Atrium and Distal Pulmonary Vein Morphology Using Multidimensional Computed Tomography. American College of Cardiology – published online (2003 April 16) 41(8):1349-7. Available at http://content.onlinejacc.org (accessed – 2007 February 15).
  19. Burgstahler, C., Kuettner, A., et al. Non-invasive evaluation of coronary artery bypass grafts using multi-slice computed tomography: Initial clinical experience. International Journal of Cardiology (2003 August) 90(2-3):275-80.
  20. Schwartzman, D. Multidimensional characterization of left atrial anatomy: essential images or pretty pictures?  Journal of Cardiovascular Electrophysiology (2004 April) 15(4):394-5.
  21. Mansour, M., Holmvang, G., et al. Role of imaging techniques in preparation for catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology (2004 September) 15(9):1107-8.
  22. Jongbloed, M.R.M., Dirksen, M.S., et al. Atrial fibrillation: multi-detector row CT of pulmonary vein anatomy prior to radiofrequency catheter ablation – initial experience. Radiology (2005) 234(3):702-9.
  23. JACC – Jongbloed, M.R.M., Bax, J.J., et al. Multislice Computed Tomography Versus Intracardiac Echocardiography to Evaluate the Pulmonary Veins Before Radiofrequency Catheter Ablation of Atrial Fibrillation. A Head-to-Head Comparison. American College of Cardiology – published online (2005 February 1) 45(3):344-50. Available at http://content.onlinejacc.org (accessed – 2007 February 15).
  24. Contrast-Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation. Chicago, Illinois:  Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (2005 May) 20(4):1-45.
  25. RadiologyInfo – Computed Tomography Angiography (CTA). Radiological Society of North America, Inc. (RSNA) (2006). Available at http://www.radiologyinfo.org (accessed - 2006 March 2).
  26. Hendel, R.C., Patel, M.R., et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. Journal of the American College of Cardiology (2006) 48(7):1475-97.
  27. JACC – Hendel, R.C., Patel, M.R., et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging – online appendix. Journal of the American College of Cardiology (2006) 48(7):1-34. Available at  http://www.jacc.org (accessed – 2007 February 12).
  28. AJC – Sheth, T.N., Rieber, J., et al. Usefulness of Coronary Computed Tomographic Angiography to Assess Suitability for Revascularization in Patients With Significant Coronary Artery Disease and Angina Pectoris. American Journal of Cardiology Online (2006) 98:1198-1201. Available at http://www.AJConline.org (accessed – 2007 February 20).
  29. AHA – Budoff, M.J., Achenbach, S., et al. Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation (online version of the American Heart Association) (2006) 114:1761-91. Available at http://circ.ahajournals.org (accessed – 2007 June 12).
  30. Kistler, P.M., Earley, M.J., et al. Validation of three-dimensional cardiac imaging integration: use of integrated CT image into electroanatomic mapping system to perform catheter ablation of atrial fibrillation. Journal of Cardiac Electrophysiology (2006 April) 17(4):341-8.
  31. Wongcharoen, W., Tsao, H., et al. Preexisting pulmonary vein stenosis in patients undergoing atrial fibrillation: A report of five cases. Journal of Cardiac Electrophysiology (2006 April) 17(4):423-5.
  32. Schoenhagen, P., Stillman, A.E., et al. Coronary artery imaging with multidetector computed tomography: A call for an evidence-based, multidisciplinary approach. American Heart Journal (2006 May) 151:945-8.
  33. Wongcharoen, W., Tsao, H., et al. Morphologic characteristics of the left atrial appendage, roof, and septum: implications for the ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology (2006 September) 17(9):951-6.
  34. Kistler, P.M., Rajappa, K., et al. The impact of CT image integration into an electroanatomic mapping system on clinical outcomes of catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology (2006 October) 17(10):1093-1101.
  35. Heist, E.K., Chevalier, J., et al. Factors affection error in integration of electroanatomic mapping with CT and MR imaging during catheter ablation of atrial fibrillation. Journal of Interventional Cardiac Electrophysiology (2006 October) 17(1):21-7.
  36. Dowe, D.A. How to win the coronary CTA turf war. American Journal of Roentgenology (2006 October) 187:849-51.
  37. AJC – Hecht, H.S. and G. Roubin. Usefulness of Computed Tomographic Angiography Guided Percutaneous Coronary Intervention. American Journal of Cardiology Online (2007) 99:871-5. Available at http://www.AJConline.org (accessed – 2007 February 20).
  38. Greenland, P., Bonow, R.O., et al. ACCR AHA 2007 clinical expert consensus document on coronary artery calcium scoring by compute tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Journal of the American College of Cardiology (2007) 49(3):378-402.
  39. Redberg, R.F. Evidence, appropriateness, and technology assessment in cardiology: A case study of computed tomography. Health Affairs (2007 January – February) 26(1):86-95.
  40. Caplan, S., Rollins, J.A., et al. Commentary: Medicare Coverage Advisory Committee meeting on noninvasive imaging for coronary artery disease. American Heart Journal (2007 February) 153:159-60.
  41. Patel, M.R., Hurwitz, L.M., et al. Noninvasive imaging for coronary artery disease: A technology assessment for the Medicare Coverage Advisory Commission. American Heart Journal (2007 February) 153:161-74.
  42. JACC – Goldstein, J.A., Gallagher, M.J., et al. A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain. Journal of the American College of Cardiology – published online (2007 February 9). Available at http://content.onlinejacc.org (accessed – 2007 February 12).
  43. AHA – Rubinshtein, R., Halon, D.A., et al. Usefulness of 64-Slice Cardiac Computed Tomography for Diagnosing Acute Coronary Syndromes and Predicting Clinical Outcome in Emergency Department Patients With Chest Pain of Uncertain Origin. Circulation (online version of the American Heart Association) (2007) 115:1762-8. Available at http://circ.ahajournals.org (accessed – 2007 April 2).
History
March 1, 2010 Deleted CPT codes: 0144T, 0145T, 0146T, 0147T, 0148T, 0149T, 0150T, 0151T
April 11, 2011 Removed CPT code 75571 which is specific to coronary artery calcification.
May 2012 Policy updated with literature review. Extensive rewrite of policy rationale and policy statement based on results of TEC Assessment. Medically necessary indication added for acute chest pain in the emergency setting. References 9,10-15, 17-19, 23-26 removed. New references 1-5, 7,8,11,13,15,16,20-22,23-45,47-56 added.
April 2013 Policy formatting and language revised.  Title changed from "Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation' to "Computed Tomography (CT) Angiography (CTA) Using Advanced CT Systems".  Added criteria to the Medically Necessary statement regarding detection of coronary artery disease and evaluation of cardiac structure and function.  Added criteria that a 64-slice or greater MDCT scanner must be used.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Computed Tomography (CT) Angiography (CTA) Using Advanced CT Systems