BlueCross and BlueShield of Montana Medical Policy/Codes
Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA)
Chapter: Radiology
Current Effective Date: April 01, 2014
Original Effective Date: May 01, 2006
Publish Date: January 13, 2014
Revised Dates: May 3, 2012; December 10, 2013; January 13, 2014
Description

Contrast-enhanced coronary computed tomography angiography (CCTA) is a non-invasive imaging technique that requires the use of intravenously administered contrast material and high-resolution, high-speed computed tomography (CT) machinery to examine blood flow by delineating the vascular anatomy. It is a potential alternative to current diagnostic tests for cardiac ischemia, i.e., non-invasive stress testing and/or invasive coronary angiography (ICA). Common CCTA 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 CCTA 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. Electrocardiograph (ECG or EKG) triggering or retrospective/prospective 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 CCTA examination.
  3. Rapid scanning is essential for image acquisition during patient breath-holding.
  4. 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.
  5. 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 variety of noninvasive tests are used in the diagnosis of coronary artery disease (CAD). They can be broadly classified as those that detect functional or hemodynamic consequences of obstruction and ischemia (exercise treadmill testing, myocardial perfusion imaging [MPI], stress echo with or without contrast), and others that identify the anatomic obstruction itself (coronary CCTA and magnetic resonance imaging [MRI]). (1) Functional testing involves inducing ischemia by exercise or pharmacologic stress and detecting its consequences. However, not all patients are candidates. For example, obesity or obstructive lung disease can make obtaining EKG images of sufficient quality difficult. Conversely, the presence of coronary calcifications can impede detecting coronary anatomy with coronary CCTA. Accordingly, some tests will be unsuitable for particular patients.

Volumetric imaging permits multiplanar reconstruction of cross-sectional images to display the coronary arteries. A CCTA to examine any blood vessel of the body includes reconstruction post-processing of angiographic images and interpretation. When using CCTA 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 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 CCTA 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. The 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.

Two different CT technologies can achieve high-speed CT imaging:

  • Electron-beam computed tomography (EBCT), also known as ultrafast CT uses an electron gun rather than a standard x-ray tube to generate x-rays, thus permitting very rapid scanning. This type of advanced high-speed digital technology with rapid scan times freezes moving organs (stop-action pictures of the heart between heartbeats) 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, on the order of 50-100 milliseconds per image. 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.
  • Helical computed tomography (Helical CT), also referred to as Spiral CT, also creates images or slices at greater speeds than conventional CT by continuously 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. Helical CT is able to achieve scan times of 500 milliseconds or less per image and use of partial ring scanning or post-processing algorithms may reduce the effective scan time even further.

Multiple-detector row helical computed tomography (MDCT) or multiple-slice CT (MSCT) is a technologic evolution of helical CT with a higher resolution and higher speed. MDCT captures multiple slices for each detector, in which a MDCT may have as few as 4, 8, 16, 32, or 40 detectors (creating numerous pie-shape wedges). MDCT machines currently in use have 64 or more detectors for CCTA. 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.

Evaluation of obstructive CAD involves quantifying arterial stenoses to determine whether significant narrowing is present. Lesions with greater than 50% to 70% diameter stenosis accompanied by symptoms are generally considered significant and often result in revascularization procedures. It has been suggested that CCTA may be helpful to rule out the presence of CAD and to avoid ICA in patients with a low clinical likelihood of significant CAD. Also of note is the interest in the potential important role of non-obstructive plaques (i.e., those associated with <50% stenosis) because their presence is associated with increased cardiac event rates. (2) CCTA can also visualize the presence and composition of these plaques and quantify the plaque burden better than conventional angiography, which only visualizes the vascular lumen. Plaque presence has been shown to have prognostic importance.

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 postoperative 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. There is no specific clinical presentation to suggest a coronary artery anomaly.

CCTA 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 current generation scanners utilizing reduction techniques (prospective gating and spiral acquisition) has declined substantially—typically to under 10 mSv. For example, an international registry developed to monitor CCTA radiation recently reported a median 2.4 mSv (interquartile range, [IQR]: 1.3 to 5.5) exposure. (3) In comparison, radiation exposure accompanying rest-stress perfusion imaging ranges varies according to isotope used—approximately 5 mSv for rubidium-82 (PET), 9 mSv for sestamibi (SPECT), 14 mSv for F-18 FDG (PET), and 41 mSv for thallium; during diagnostic invasive coronary angiography, approximately 7 mSv will be delivered. (4) EBCT using EKG triggering delivers the lowest dose (approximately 0.7 to 1.1 mSv with 3-mm sections). Any cancer risk due to radiation exposure from a single cardiac imaging test depends on age (higher with younger age at exposure) and gender (greater for women). (5-7) Empirical data (8) suggest that every 10 mSv of exposure is associated with a 3% increase in cancer incidence over 5 years.

The same CCTA 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.

American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines and Definitions:

In 1999, the ACC and the 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>). (9) 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

Symbols Key:

*    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 below the last table.

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.

In 2010, the ACC and the AHA released a joint scientific report describing the appropriate use criteria for CCTA. (10) Within the joint report, ACC/AHA defined the following risk and probability terminology:

  • Absolute risk – the probability of developing CHD, including myocardial infarction (MI) or CHD death over a given period of time. The National Heart, Lung, and Blood Institute specifies absolute risk for CHD as being over the next 10 years, referring to 10-year risk for any hard cardiac event.
  • CHD Risk-Low – the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk <10%.
  • CHD Risk-Intermediate – the age-specific risk level that is average or above average. In general moderate risk will correlate with a 10-year absolute CHD risk ranging from 10% to 20%. Among women and younger men, an expanded intermediate risk range of 6% to 20% may be appropriate.
  • CHD Risk-High – the presence of diabetes mellitus in a patient ≥ 40 years of age, peripheral artery disease or other coronary risk equivalents, or the 10-year absolute CHD risk of > 20%.
  • Pretest probability – the likelihood of the presence of a condition before a diagnostic test.
  • Very low pretest probability – < 5% pretest probability of CAD.
  • Low pretest probability – < 10% pretest probability of CAD.
  • Intermediate pretest probability – Between 10% and 90% pretest probability of CAD.
  • High pretest probability – > 90% pretest probability of CAD.
  • Typical angina (definite) – substernal chest pain, or ischemic equivalent discomfort that is provoked by exertion or emotional stress AND relieved by rest and/or nitroglycerin.
  • Atypical angina (probable) – chest pain or discomfort with two characteristics of definite or typical angina.
  • Non-anginal chest pain – chest pain or discomfort that meets one or none of the typical anginal characteristics.
  • Acute coronary syndrome – includes those patients whose clinical presentations covering the following range of diagnoses: unstable angina, MI without ST-elevation, and MI with ST-elevation.
  • EKG (uninterpretable) – EKG with resting ST-segment depression, complete left bundle-branch block, pre-excitation (Wolff-Parkinson-White syndrome), or paced rhythm.
  • Able to exercise – able to complete a diagnostic exercise treadmill examination.

The ACC/AHA also provided clinicians, within the 2010 guidelines, a pretest probability of CAD by age, sex, and symptoms table to make their assessments, using the pretest categories of very low, low, intermediate, and high as defined just above:

Age

Sex

Typical/Definite

Angina Pectoris

Atypical/Probable Angina Pectoris

Non-Anginal Pain

Asymptomatic

< 39

Men

Intermediate

Intermediate

Low

Very Low

< 39

Women

Intermediate

Very Low

Very Low

Very Low

40-49

Men

High

Intermediate

Intermediate

Low

40-49

Women

Intermediate

Low

Very Low

Very Low

50-59

Men

High

Intermediate

Intermediate

Low

50-59

Women

Intermediate

Intermediate

Low

Very Low

> 60

Men

High

Intermediate

Intermediate

Low

> 60

Women

High

Intermediate

Intermediate

Low

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

Contrast-enhanced coronary computed tomography angiography (CCTA), with or without contrast enhancement or media, utilizing 64-slice or greater multi-detector row computed tomography (MDCT) scanner, as an adjunct to other testing may be considered medically necessary for the detection of coronary artery disease (CAD) in:

  • Symptomatic individuals (such as, ischemic equivalent chest pain syndrome* as described by the American College of Cardiology [ACC] and the American Heart Association [AHA]) who:
    1. Have intermediate OR low pre-test probability of CAD (as identified by the ACC/AHA guidelines); AND
    2. Had a non-diagnostic stress electrocardiograph (ECG or EKG) (as defined by the ACC/AHA 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/AHA) who:
    1. Have intermediate OR low pre-test probability of CAD (as identified by the ACC/AHA guidelines); AND
    2. Had no EKG 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.

*    The ACC/AHA defines the following conditions, “ischemic equivalent chest pain syndrome, anginal equivalent or ischemic electrocardiographic abnormalities: Any constellation of clinical findings that is clinically judged to be consistent with obstructive CAD. Examples of such findings include, but not limited to, chest pain, chest tightness, burning, shoulder pain, jaw pain, and new electrocardiographic abnormalities suggestive of ischemic heart disease. Non-chest pain symptoms, such as dyspnea or worsening effort tolerance that are felt to be consistent with CAD may also be considered to be an anginal equivalent.”

Note:   Refer to the Description in this medical policy for the definitions and guidelines, pretest probability assessment, identified by the ACC/AHA Joint Task Force.

Contrast-enhanced coronary computed tomography angiography (CCTA), with or without contrast enhancement or media, utilizing 64-slice or greater multi-detector row computed tomography MDCT scanner, 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
  • 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 (EKG), 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 EKG, 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.

CCTA, 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/or unproven.

CCTA, 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/or unproven.

CCTA, using MDCT, for any other indication not listed above, including but not limited to high or very low pretest probability of CAD, is considered experimental, investigational and/or unproven.

Note:  For any other cardiac CT calcium scoring services, see policy Cardiac Computed Tomography (CCT) for Calcium Scoring.

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 CCTA of heart and/or coronary arteries.

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

Rationale

This policy was originally based on a literature search on MedLine through February 2006 and with a May 2005 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment. (11)  The most recent literature search was done through October 2013 and included several joint reports and guidelines from the American College of Cardiology Foundation (ACCF), which includes key specialty and subspecialty societies. (9, 10, 12, 13) The societies represented within the task force are: the American College of Cardiology (ACC), the American Heart Association (AHA), the American College of Radiology (ACR), the Society of Cardiovascular Computed Tomography (SCCT), the American Society of Echocardiography (ASE), the American Society of Nuclear Cardiology (ASNC), the North American Society of Cardiovascular Imaging (NASCI), the Society of Cardiovascular Angiography (SCA), and the Society of Cardiovascular Magnetic Resonance (SCMR). Within this medical policy, reference to these reports and guidelines will be shown as ACC/AHA. Additional BCBSA TEC Assessments in 2006 and 2011 were included in the review of the key literature to date. (14, 15)

Early Evaluation of Clinical Effectiveness: The objective of the 2005 BCBSA TEC Assessment was to evaluate the clinical effectiveness of contrast-enhanced coronary cardiac computed tomography angiography (CCTA) 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 (ICA), particularly in patients with a low probability of significant coronary artery stenosis. (11) Evaluation of the coronary artery anatomy and morphology is the most frequent use of CCTA and was the primary focus of the TEC Assessment. This Assessment considered multiple indications, but computed tomography (CT) technology used in studies reviewed is now outdated (studies employed 16-slice scanners). The TEC Assessment concluded that the use of contrast-enhanced CCTA for screening or diagnostic evaluation of the coronary arteries did not meet TEC criteria.

Usefulness as a Substitute for ICA: The 2006 BCBSA TEC Assessment was undertaken to determine the usefulness of CCTA as a substitute for ICA for 2 indications: in the diagnosis of coronary artery stenosis and in the evaluation of acute chest pain in the emergency department (ER). (14) Just 7 studies performed in the ambulatory setting utilizing 40 to 64 slice scanners were identified. Two studies performed in the emergency department used 4- or 16-slice scanners. Evidence was judged insufficient to form conclusions. Available studies at the time were inadequate to determine the effect of CCTA on health outcomes for the diagnosis of coronary artery stenosis in patients referred for angiography or for evaluation of acute chest pain in the ER.

Other Diagnostic Uses of CCTA: Given its ability to define coronary artery anatomy, there are many other potential diagnostic uses of CCTA including patency of coronary artery bypass grafts (CABG), in-stent restenosis, screening, and preoperative. Evaluating patency of vein grafts is generally less of a technical challenge due to their size and lesser motion during imaging. In contrast, internal mammary grafts may be more difficult to image due to their small size and presence of surgical clips. Finally, assessing native vessels distal to grafts presents difficulties due to their small size and when calcifications are present. For example, a 2008 meta-analysis including results from 64-slice scanners, reported high sensitivity 98% (95% CI: 95 to 99; 740 segments) and specificity 97% (95% CI: 94 to 97). (15) Other small studies have reported high sensitivity and specificity. (16, 17) Lacking are multicenter studies demonstrating likely clinical benefit, particularly given the reasonably high disease prevalence in patients evaluated. Use of CCTA for evaluation of in-stent restenosis presents other technical challenges—motion, beam hardening, and partial volume averaging. Whether those challenges can be sufficiently overcome to obtain sufficient accuracy and impact outcomes has not been demonstrated. The use for screening a low-risk population was recently evaluated in 1,000 patients undergoing CCTA compared to a control group of 1,000 similar patients. (18) Findings were abnormal in 215 screened patients. Over 18 months’ follow-up, screening was associated with more invasive testing, statin use, but without difference in cardiac event rates. Lastly, CCTA for preoperative evaluation before non-cardiac surgery has been suggested, evaluated in only small studies, and lacking demonstrable clinical benefit.

During the literature review, relevant studies were identified, which included multicenter studies comparing diagnostic performance of CCTA to ICA studies of incidental findings, radiation exposure, prognosis, and studies of downstream or subsequent testing—all important considerations when comparing CCTA in the diagnostic-treatment pathway to alternatives.

Diagnostic Accuracy: Four multicenter studies evaluated the diagnostic accuracy of CCTA employing ICA as referent standard. All patients enrolled in the 4 studies were scheduled for ICA; the population of interest here are patients at intermediate risk only, a minority of whom would proceed to ICA.

ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) compared CCTA to ICA in 230 of 245 individuals experiencing typical or atypical chest pain referred for non-emergent ICA. (19) Three readers blinded to ICA results interpreted CCTA scans. Of the 143 normal CCTA scans, ICA was normal in 142 (negative predictive value [NPV] 99%); the false-positive rate was 17%. Radiation dose, prevalence of incidental non-cardiac findings, and follow-up were not reported in the report. Using a 50% stenosis cutoff, disease prevalence was 25%, with 13% having 70% or greater stenosis. Estimated pretest disease probability was not reported.

CORE 64 (Coronary Artery Evaluation Using 64-Row MDCT Angiography) evaluated 405 individuals referred for ICA to evaluate suspected CAD at 9 centers. (20) There were 89 patients (22%) excluded from analyses due to Agatston calcium score greater than 600; results from 291 of 316 remaining individuals were analyzed. CCTA was the initial diagnostic test, and investigators and physicians were subsequently blinded to CCTA results. Sensitivity was 85%, negative predictive value (NPV), 83%, and false-positive rate, 10%. CCTA radiation dose was 13.8 ± 1.2 mSv for men and 15.2 ± 2.4 mSv for women. Noncardiac findings were reported to the treating physician but were not described in the report. Disease prevalence was 56%, using a 50% stenosis cutoff. Pretest disease probability was not reported.

Meijboom et al. (21) evaluated 433 individuals, aged 50 to 70 years, seen at 3 university hospitals referred for ICA to evaluate suspected stable or unstable angina; 371 consented to participate and 360 completed the study. Tests were interpreted in blinded fashion. Sensitivity was 99%, NPV, 97%, and false-positive rate, 36%. Estimated radiation exposure based on instrument parameters ranged from 15 to 18 mSv. The frequency of noncardiac findings was not reported. Disease prevalence was 68%, using a 50% stenosis cutoff; pretest probability was not reported.

Chow et al. (22) gained consent from 181 patients and examined 169 from 250 eligible patients referred to ICA for evaluation of CAD (n=117) or structural heart disease (n=52). Four centers evaluated differing numbers of patients—102 (60.3%), 40 (23.7%), 16 (9.5%), and 11 (6.5%), respectively. Overall sensitivity for obstructive CAD was 81%, NPV, 85%, and false positive rate, 7%. Performance characteristics differed substantially and significantly by site. The center enrolling the majority of patients reported sensitivity, specificity, NPV and positive predictive values (PPVs) of 93%, 93%, 91%, and 95%, respectively; the other 3 centers 67%, 93%, 92%, and 71%. Average radiation exposure was estimated to be 11.0 ± 6.8 mSv. Disease prevalence was 53%, using a 50% stenosis cutoff and mean estimated pretest probability of CAD 47%.

There was variability in CCTA diagnostic accuracy reported from these multicenter studies spanning different disease prevalence populations. The lower sensitivity reported by Chow et al. (25) is of note alongside the considerable between-center variability. In contrast to the others, the study used visual ICA assessment as a reference standard. While arguably, visual assessment is most often used in practice, it is prone to imprecision. (23, 24) Although Chow et al. (22) reported high inter-observer agreement for ICA (kappa=0.88), Zir et al. (27) found 4 experienced observers agreed 65% of the time whether a stenosis exceeded 50% in 20 angiograms. Finally, the small number of patients enrolled from 3 centers relative to overall annual CCTA volume (center 1—102/1,325; 2—40/1,539; 3—11/1,773; 4—16/268) might reflect sampling variability (screening procedures or whether consecutive patients were approached was not reported).

Patient populations included in each study varied, as did disease prevalence. Estimates of pretest disease probability were not reported except by Chow et al., (22) but given that all patients were referred to ICA, they were presumably at least in the upper intermediate probability range. With those caveats, the studies support concluding that CCTA is sensitive for detecting stenoses in samples with varying disease prevalences. Sensitivities are at least as good those cited for other noninvasive tests; false positives are not uncommon, but the rate is similar to other noninvasive tests. However, as suggested by Chow et al. (22) sensitivity and specificity achieved in the real world are likely lower than those reported under more carefully controlled conditions. These results are, however, subject to verification bias, (25) as all patients were referred for ICA. The performance characteristics reported from these studies, as well as for accuracy studies of some non-invasive test among patients selectively referred to ICA, might differ in practice when the test is used in patients not referred. In comparison, a recent meta-analysis including smaller single center studies (42 total) estimated pooled sensitivity and specificity of 98% and 85%. (26) Finally, radiation exposure reported in these studies is consistent with others using retrospective gating. Current prospective gating techniques will result in lower radiation doses.

Other important outcomes that require consideration in comparing technologies include ICA rates, use of a second non-invasive test, radiation exposure, and follow-up of any incidental findings. While there is uncertainty accompanying the limited trial evidence, it is reasonable to conclude that the ICA rate following CCTA is not markedly different to that following perfusion imaging. Two studies showed that subsequent diagnostic testing was more frequent in subjects receiving CCTA. Studies have differed in which treatment strategy results in higher overall radiation exposure. Incidental findings following CCTA are common and lead to further testing, but the impact of these findings on subsequent health outcomes is uncertain.

Incidental Findings: Nine studies using 64+ slice scanners were identified. (27-35) Incidental findings were frequent (26.6% to 68.7%) with pulmonary nodules typically the most common and cancers rare (approximately 5/1,000 or less). Aglan et al. (27) compared the prevalence of incidental findings when the field of view was narrowly confined to the cardiac structures seen when the entire thorax was imaged. As expected, incidental findings were less frequent in the restricted field (clinically significant findings in 14% versus 24% when the entire field was imaged).

Prognosis: Hulten et al. (36) performed a meta-analysis of 18 studies (n=9,592) with 3 or more months’ follow-up (median 20 months) enrolling patients with suspected CAD (mean age 59 years, 58% male). Annualized death or MI rates after a normal CCTA (no identified stenosis >50%) was 0.15%. The pooled rate included 2 studies of EBCT and 4 that utilized 16 slice scanners; most events in the normal group occurred in one of the EBCT studies. Bamberg et al. (37) pooled results from 9 studies (n=3,670) enrolling ≥100 patients with ≥1 year follow-up enrolling patients with suspected CAD (mean age 59.1±2.6 years, 63% male). The pooled annualized event rate (all-cause and cardiac death, MI, unstable angina, revascularization) was 1.1% following a CCTA without evidence of significant stenosis; in the 38% of patients without evidence of any atherosclerotic plaque, the annual event rate 0.4%. In comparison, Metz et al. (38) performed a meta-analysis of event rates following a negative MPI and stress echocardiography. The pooled annual cardiac death and MI rates following negative MPI (17 studies; 8,008 patients) and stress echocardiography (4 studies; 3,021 patients) were 0.45% and 0.51%, respectively.

Subsequent or Downstream Testing: Whether tests are used to replace, or add to, others currently in use are relevant. Few studies have addressed this issue. In an analysis of 2006 data from patients without CAD, as recorded in claims, Min et al. (39) found that following MPI, 11.6% of 6,588 patients underwent subsequent MPI, CCTA, or ICA; following CCTA, 14.6% of 1,647 patients underwent one of those tests. A study of Medicare claims from 2005-2008 showed different results. (40) Compared with MPI, patients undergoing CCTA had a higher likelihood of subsequent cardiac catheterization (22.9% vs. 12.1%), and higher rates of percutaneous coronary procedures and bypass surgery. Aggregate healthcare spending was higher in subjects who had CCTA. More recently, Cheezum et al. (41) retrospectively identified 241 symptomatic patients without known CAD undergoing CCTA and matched them by age and gender to 252 also symptomatic patients undergoing MPI. Downstream testing was less frequent following CCTA than MPI (11.5% vs. 17.0%), as well as ICA (3.3% vs. 8.1%). Finally, CCTA and ICA in Ontario are centralized to a single academic center in Ottawa, which allowed investigators to examine CCTA accuracy concurrent with the impact on ICA referrals (42) Consecutive patients (n=3,538) were evaluated by ICA during 14 months before and in the 12 months after (n=3,479) CCTA introduction. The rate of normal ICA decreased from 31.5% before to 26.8% after CCTA introduction (p=0.003). During the same period at 3 other centers without CCTA programs, normal ICA rates increased from 30.0% to 31.0%. Given that all these studies are observational, it is difficult to make solid conclusions on the impact of use of CCTA on overall utilization of subsequent diagnostic and therapeutic procedures.

Radiation Exposure: Exposure to ionizing radiation increases lifetime cancer risk. (BEIR VII, 43) Three studies have estimated excess cancer risks due to radiation exposure from CCTA. (6, 7, 47) Assuming a 16-mSv dose, Berrington de Gonzalez et al. (44) estimated that the 2.6 million CCTAs performed in 2007 would result in 2,700 cancers or approximately 1 per 1,000. Smith-Bindman et al. (7) estimated that cancer would develop in 1 of 270 women and 1 of 600 men age 40 undergoing CCTA with a 22-mSv dose. Einstein et al. (6) employed a standardized phantom to estimate organ dose from 64-slice CCTA. With modulation and exposures of 15 mSv in men and 19 mSv in women, the calculated lifetime cancer risk at age 40 was 7 per 1,000 men (1 in 143) and 23 per 1,000 women (1 in 43). However, estimated radiation exposure used in these studies is considerably higher than received with current scanners—now typically under 10 mSv and often less than 5 mSv with contemporary machines and radiation reduction techniques. For example, in the 47-center PROTECTION I study enrolling 685 patients; the mean radiation dose was 3.6 mSv, using a sequential scanning technique. (45) In a study of patients undergoing an axial scanning protocol, mean radiation dose was 3.5 mSV, and produced equivalent ratings of image quality compared to helical scan protocols, which had much higher mean radiation doses of 11.2 mSv. (46)

Although indirectly related to CCTA, Eisenberg et al. (6) analyzed administrative data from 82,861 patients undergoing imaging or procedure accompanied by radiation between April 1996 and March 2006 with 12,020 incident cancers identified. Based on estimated radiation exposures accompanying various cardiac imaging and procedures, over 5 years, there was an increased relative hazard for cancer of 1.003 per mSv (95% confidence interval [CI]: 1.002-1.004).

CCTA Utilization in the ER Setting: A 2011 BCBSA TEC Assessment examined evidence surrounding the evaluation of patients with acute chest pain and without known coronary artery disease (CAD). (47) The 2010 ACCF with the AHA expert consensus report on CCTA included a statement regarding CCTA use in the ER. (12) The evaluation of patients with an acute coronary syndrome, not having EKG changes or positive cardiac markers may be useful. Additionally randomized controlled trials (RCTs) and prospective observational studies reporting prognosis were identified by searching the MedLine database and relevant bibliographies of key studies.

Several RCTs of CCTA conducted in ER settings were identified. An RCT of Goldstein et al. evaluated 197 randomized patients from a single center without evidence of acute coronary syndromes to CCTA (n=99) or usual care (n=98). (48) Over a 6-month follow-up, no cardiac events occurred in either arm. ICA rates were somewhat higher in the CCTA arm (12.1% vs. 7.1%). Diagnosis was achieved more quickly following CCTA. A second trial (CT-STAT) evaluated a similar sample of 699 randomized patients from 16 centers—361 undergoing CCTA and 338 myocardial perfusion imaging (MPI). (49) Over a 6-month follow-up, there were no deaths in either arm, 2 cardiac events in the CCTA arm and 1 in the perfusion imaging arm. ICA rates were similar in both arms (7.2% after CCTA; 6.5% after perfusion imaging). A second non-invasive test was obtained more often following CCTA (10.2% versus 2.1%), but cumulative radiation exposure in the CCTA arm (using retrospective gating) was significantly lower—mean 11.5 versus 12.8 mSv. Time to diagnosis was shorter (mean 3.3 hours) and estimated ER costs lower with CCTA.

An RCT by Litt et al. also evaluated the safety of CCTA in the evaluation of patients in the ER. (50) Although the study was a randomized comparison to traditional care, the principal outcome was the safety outcomes of subjects with negative CCTA examinations. No patients who had negative CCTA examinations (n=460) died or had a myocardial infarction (MI) within 30 days. Compared with traditional care, patients in the CCTA group had higher rates of discharge from the ER (49.6% vs. 22.7%), a shorter length of stay (median 18.0 hours vs. 24.8 hours), and a higher rate of detection of coronary disease (9.0% vs. 3.5%). Another RCT by Hoffmann et al. compared length of stay and patient outcomes in patients evaluated with CTA versus usual care. (51) In patients in the CCTA arm of the trial, the mean length of stay in the hospital was reduced by 7.6 hours, and more patients were discharged directly from the ER (47% vs. 12%). There were no undetected coronary syndromes and no differences in adverse events at 28 days. However, in the CCTA arm, there was more subsequent diagnostic testing and higher cumulative radiation exposure. The cumulative costs of care were similar between the two groups.

Two studies reported no cardiac events following a negative CCTA in the ER after 12 months’ (n=481) (52) and 24 months’ (n=368) (53) follow-up.

An overall assessment of the studies would appear to provide the following conclusions. Owing to the high negative predictive value of CCTA in this population of patients presenting to the ER with chest pain, the test offers an alternative for patients and providers. Evidence obtained in the emergency setting, similar to more extensive results among ambulatory patients, indicates a normal CCTA provides a prognosis at least as good as other negative non-invasive tests. The efficiency of the workup is improved, as patients are more quickly discharged from the ER with no adverse outcomes among patients who have negative CCTA examinations.

Practice Guidelines and Position Statements

ACC/AHA Guidelines and Reports: Appropriate use criteria and expert consensus documents have been published jointly by ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT (9, 10, 12, 13, 54), but U.S. guidelines have not been developed. The initial joint scientific statement from the ACC/AHA in 1999 provided the identification of risk factors to reduce the risk for cardiovascular disease and coronary heart disease and outlines approaches to global risk assessment for primary prevention. (9) The authors concluded that the joint statement provided critical background information that can be used in the development of treatment guidelines for practitioners.

The 1999 scientific statement laid out absolute risk versus relative risk estimates, based on the Framingham report and scoring. (9)  The absolute risk is expressed as the percentage likelihood of developing CHD per decade. Whereas the relative risk is the ratio of absolute risk group (those patients developing CHD) to that of a low risk group (those individuals who are unexposed to conditions leading to CHD). Risk factors affect the scoring and estimation of absolute risk. These factors identified included age, sex, smoking, hypertension, hypercholesterolemia, hypertriglyceridemia, diabetes mellitus, obesity, inactivity, family history, ethnic characteristics, and psychological factors.

In 2006, Hendel and colleagues, along with key specialty and subspecialty societies compiled a grouping of indications and applications for CCTA as few clinical practice guidelines currently existed. (54) This consensus approach was to evaluate the test performance of CCTA by purpose and within specific clinical scenarios. 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 CCTA 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 CCTA 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 an intermediate probability of CAD when EKG was uninterpretable, or in the evaluation of chest pain syndrome with uninterpretable or equivocal stress tests. In addition, CCTA was considered appropriate to evaluate coronary arteries etiology in patients with new onset heart failure.

In 2006, the AHA released a scientific assessment of CCTA utilization referenced the 2006 ACC Appropriateness Criteria. (55) 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).” 

In response to improvements in and the application of cardiovascular imaging technology, the ACCF critically and systematically created, reviewed, and categorized clinical situations where CCTA is appropriately utilized. (10) This 2010 report defined pretest probability and criteria, utilized in the coverage position of this policy, to guide the practitioner in the rationale use of CCTA, avoiding under- or overutilization, determining the net benefit of the testing, and thereby lead to an increased optimal healthcare delivery for the patient. Each clinical scenario or indication was rated and scored in two rounds using categories of:

  • Appropriate (score 7 to 9) test for a specific indication, as the test (CCTA) is generally acceptable and is a reasonable approach for the indication; 
  • Uncertain (score 4 to 6) for the indication, as the test (CCTA) may be generally acceptable and may be a reasonable approach for the indication. Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively; and
  • Inappropriate (score 1 to 3) test for the specific indication, as the test (CCTA) is not generally acceptable and is not a reasonable approach for the indication.

A total of 31 indications were carried forward from the 2006 ACC Appropriateness Criteria document. (10) Some changes to the ratings occurred, 8 shifted up one category from either uncertain to appropriate or from inappropriate to uncertain. The balance remained unchanged. One of the areas of expansion involves symptomatic patients without known heart disease. CCTA was felt to be appropriate primarily for situations involving a low or intermediate pretest probability of obstructive CAD. Clinical scenarios involving high-probability of CAD were rated as uncertain with the exception of a patient with an interpretable EKG who was able to exercise, and for definite MI. However, those patients presenting with very low or high pretest probability of obstructive CAD were classified as uncertain or inappropriate, as very low is determined to have less than 5% probability of developing CAD in the next decade and high has a 90% probability of developing obstructive CAD resulting from additional comorbidities.

Screening for CAD: No eligible studies were identified using CCTA as a screening test for CAD in asymptomatic subjects or among subjects planned for major noncardiac surgery. The ACC/AHA in 2010 released a guideline for the assessment of cardiovascular risk in asymptomatic adults. (12) At this time, there is no benefit to screening for cardiovascular risk in asymptomatic adults using CCTA (Level of Evidence:C).

Summary

In patients presenting to ER settings with acute chest pain that is possibly cardiac in origin and no known history of CAD, the net health outcome following CCTA appears at least as good as that obtained following other noninvasive testing strategies. CCTA can rule out active coronary disease with a high rate of certainty in patients with low-to-moderate (intermediate) pre-test probabilities of CAD. In addition, it is a more efficient strategy in the ER setting compared to alternative approaches. Consequently, CTA may be considered medically necessary for use in this patient population.

Therefore, these additions to detection of CAD in symptomatic patients with or without known heart disease and variable clinical presentations lead to considering CCTA as medically necessary for low pretest probability when meeting specific criteria. Intermediate pretest probability remained unchanged and considered medically necessary when meeting specific criteria. Evaluation of cardiac structure and function using CCTA remained unchanged and medically necessary for specific clinical conditions. The ACC/AHA Appropriateness Criteria confirmed the uncertain or inappropriate use rating to use CCTA for high and very low pretest probability of CAD. Hence, using CCTA for those clinical scenarios or indications that would be considered high or very low pretest probability were added to the coverage position as experimental, investigational and/or unproven.

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, B221Y0Z, BW03ZZZ

Procedural Codes: 75571, 75572, 75573, 75574
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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.
December 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.
April 2014 Document updated with literature review. The following was added: 1) Low pretest probability for symptomatic individuals was added as medically necessary; and 2) high or very low pretest probability for CAD was added as examples that are considered experimental, investigational and/or unproven. The Description and Rationale were significantly revised. The title was changed from: Computed Tomography (CT) Angiography (CTA) Using Advanced CT Systems.  Removed codes 71275 and S8092.
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Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA)