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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 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® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70450-03

Original Effective Date: 12/15/04

Reviewed: 12/05/13

Revised: 01/01/14

Subject: Computed Tomographic Angiography (CTA) Heart

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Update  

DESCRIPTION:

Computed tomographic angiography (CTA) is a noninvasive imaging test that requires the use of intravenously administered contrast material and high-resolution, high-speed CT machinery to obtain detailed volumetric images of blood vessels. CTA can be applied to image blood vessels throughout the body; however, to apply CTA in the coronary arteries, several technical challenges must be overcome to obtain high-quality diagnostic images. First, 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 down the heart rate below about 60 – 65 beats per minute to facilitate adequate scanning, and electrocardiographic triggering or retrospective gating is used to obtain images during diastole when motion is reduced. Second, rapid scanning is also helpful so that the volume of cardiac images can be obtained during breath-holding. Third, very thin sections (< = 1mm) are important to provide adequate spatial resolution and high-quality 3D reconstruction images.

CTA has several limitations. The presence of dense arterial calcification or an intracoronary stent can produce significant beam-hardening artifacts that may preclude a satisfactory study. The presence of an uncontrolled rapid heart rate or arrhythmia hinders the ability to obtain diagnostically satisfactory images. 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.

CTA may contribute to refined risk assessment in certain subsets of the population, there are currently no clinical data to support its use or upon which to base therapeutic recommendations. Current scientific evidence to justify widespread use of this rapidly evolving technology in broad clinical populations remains undefined. Therefore, it is currently not recommended to use CTA for routine screening. Scientific evidence to justify widespread use of CTA in broad clinical populations remains undefined (Gibbons et al. 2006). Exposure to radiation and contrast agents are concerns with CTA. Radiation exposure (quantified at 3 – 4 times the radiation exposure compared to diagnostic invasive angiography) and the use of iodinated contrast can be nephrotoxic for certain individuals (Patel et al. 2007).

POSITION STATEMENT:

Computed tomographic angiography (CTA) performed for the evaluation of the heart and coronary arteries using a 64-slice scanner or greater meets the definition of medical necessity for the following indications:

The following indications meet the definition of medical necessity for new or changing signs or symptoms:

Computed tomographic angiography (CTA) of the heart and coronary arteries is considered experimental or investigational for the following indications, including but not limited to:

Computed tomography, heart meets the definition of medical necessity for the following indications:

BILLING/CODING INFORMATION:

The following code(s) may be used to describe computed tomographic angiography (CTA) for coronary artery evaluation.

CPT Coding:

75572

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)

75573

Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)

75574

Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

REIMBURSEMENT INFORMATION:

Table 1: Determination of Pretest Probability for Coronary Disease Based on Age, Gender, and Symptoms (Source: American College of Cardiology Criteria for Pretest Probability of Coronary Artery Disease (CAD).

The following risk assessment may be used to determine pre-test probability of coronary artery disease.

Table 1:

Age (years)

Gender

Typical/Definite Angina Pectoris

Atypical/Probable Angina Pectoris

Nonanginal Chest Pain

Asymptomatic

30 – 39

Men

Intermediate

Intermediate

Low

Very low

 

Women

Intermediate

Very low

Very low

Very low

40 – 49

Men

High

Intermediate

Intermediate

Low

 

Women

Intermediate

Low

Very low

Very low

50 – 59

Men

High

Intermediate

Intermediate

Low

 

Women

Intermediate

Intermediate

Low

Very low

60 – 69

Men

High

Intermediate

Intermediate

Low

 

Women

High

Intermediate

Intermediate

Low

High: Greater than 90% pre-test probability

Intermediate: Between 10% and 90% pre-test probability

Low: Between 5% and 10% pre-test probability

Very low: Less than 5% pre-test probability

Angina: As defined by the American College of Cardiology (ACC)/American Heart Association (AHA)

Typical Angina (Definite): 1.) Substernal chest pain or discomfort that is 2.) Provoked by exertion or emotional stress and 3.) Relieved by rest and/or nitroglycerine.

Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

Non-Anginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Table 2: Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Framingham risk assessment is a calculation to predict the 10-year risk of heart disease. The calculation is based on the individual’s age, sex, most recent lipid values, blood pressure, smoking history, and presence of diabetes.

Table 2:

CHD Risk Level

Framingham Score

CHD Risk-Low Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk.

Less than 10%

CHD Risk-Moderate Defined by the age-specific risk level that is average or above average.

Between 10% and 20%

CHD Risk-High Defined as the presence of diabetes mellitus.

Greater than 20%

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment, laboratory studies and reason for computed tomographic angiography (CTA).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02

OTHER:

Other names used to report computed tomographic angiography (CTA) for coronary artery evaluation:

Cardiac Computed Tomography (CCT) (or CT Angiography)
Coronary angiography (CCTA)
Multi-detector row computed (computerized) tomography (MDCT)
Multi-slice spiral computed (computerized) tomography (MSCT)

REFERENCES:

  1. American College of Radiology (ACR) Practice Guideline for the Performance and Interpretation of Computed Tomography Angiography (CTA), 10/01/05.
  2. American Medical Association Clinical Examples in Radiology Vol. 1, Bulletin 2, 2005, pp.1-3.
  3. Andreini D, Pontone G, Pepi M et al. Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with dilated cardiomyopathy. Journal of American College of Cardiology 2007 May 22; 49(20): 2044 – 50.
  4. Berman DS, Hachamovitch r, Shaw LJ et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: Noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. The Journal of Nuclear Medicine; 47(7): 1107 – 1118.
  5. Blue Cross Blue Shield Association Medical Policy. Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation (6.01.43), 11/12.
  6. Blue Cross Blue Shield Association TEC Assessment. Contrast-Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation 05/05, Vol. 20, No. 4.
  7. Blue Cross Blue Shield Association TEC Assessment. Contrast-Enhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary Artery Stenosis or for Evaluation of Acute Chest Pain, August 2006, Vol. 21, No. 5.
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  12. Center for Medicare & Medicaid Services (CMS) First Coast Service Options, Inc.-LCD for Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries, 02/02/09.
  13. Center for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCD)-Computerized Tomography, (220.1), 03/12/08
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  29. Gasper T, Halon D, Lewis BS Diagnosis of Coronary in-stent restenosis with multidetector row spiral computed tomography. Journal of the American College of Cardiology 2005; 46(8): 1573 – 1579.
  30. Ghostine S, Caussin C, Daoud B et al. Non-invasive detection of coronary artery disease in patients with left bundle branch block using 64-slice computed tomography. Journal of the American College of Cardiology 2006; 48: 1929 – 1934.
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  32. Gibbons RJ, Eckel RH, Jacobs AK et al. The utilization of cardiac imaging. Circulation 2006; 113; 1715:1716.
  33. Goldstein JA, Gallagher MJ, O'Neill WW 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 2007; 49(8): 863 – 871.
  34. Hacker M, Jakobs T, Matthiesen F et al. Comparison of spiral multidetector CT angiography and myocardial perfusion imaging in the noninvasive detection of functionally relevant coronary artery lesions: first clinical experiences. The Journal of Nuclear Medicine 2005; 46(8): 1294 – 1300.
  35. Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology 2009; 252(2): 332 – 345.
  36. Hamon M, Morello R, Riddell JW et al. Coronary Arteries: Diagnostic Performance of 16- versus 64-Section Spiral CT Compared with Invasive Coronary Angiography Meta-Analysis. Radiology 2007; 245(3): 720 – 731.
  37. Hausleiter, J, Meyer T, Hermann F et al. Estimated radiation dose associated with cardiac CT angiography. The Journal of the American Medical Association 2009; 301(5): 500 – 507.
  38. Hendel RC, Budoff MJ, Cardella JF et al. ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key data elements and definitions for cardiac imaging: a report of the American College of Cardiology/American Heart Association task force on clinical data standards (writing committee to develop clinical data standards for cardiac imaging). Journal of the American College of Cardiology 2009; 53: 91 – 124.
  39. Hendel RC, Patel MR, Kramer CM et al. ACCF/ACR/SCCT/SCMR/ ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging-A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. Journal of the American College of Cardiology 2006; 48(7): 1475 – 1497.
  40. Hlatky MA. Evaluating use of coronary computed tomography angiography in the emergency department (editorial comment). Journal of the American College of Cardiology 2009; 53(18): 1651 – 1652.
  41. Hoffman MHK, Shi H, Schmitz B, et al. Noninvasive Coronary Angiography with Multislice Computed Tomography. Journal of the American Medical Association (JAMA) Vol 293, NO. 20: 2471 – 2478.
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  43. Hoffmann U, Bamberg F, Chae Cu et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. Journal of the American College of Cardiology 2009; 53(18): 1642 – 1650.
  44. Hoffmann U, Bamberg F, Chae Cu et al. Coronary computed tomography antiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial. Journal of the American College of Cardiology 2009; 53(18): 1642 – 1650.
  45. Hollander JE, Chang AM, Shofer FS et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Academic Emergency Medicine 2009; 16(8): 693 – 698.
  46. Hurwitz LM, Reiman RE, Yoshizumi TT et al. Radiation dose from contemporary cardiothoracic multidetector CT protocols with an anthropomorphic female phantom: implications for cancer induction. Radiology 2007; 245(3): 742 – 750.
  47. Jones CM, Athanasiou T, Dunne N et al. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Annals of Thoracic Surgery 2007; 83(1): 341-348.
  48. Khare RK, Courtney DM, Powell ES et al. Sixty-four-slice computed tomography of the coronary arteries: cost-effectiveness analysis of patients presenting to the emergency department with low-risk chest pain. Academic Emergency Medicine 2008; 15(7): 623 – 632.
  49. Kramer CM, Budoff MJ, Fayad ZA et al. Journal of the American College of Cardiology 2007; 50(11): 1097 – 1114.
  50. Kuettner A, Kopp AF, Schroeder S et al. Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with angiographically proven coronary artery disease. Journal of the American College of Cardiology 2004; 43: 831 – 839.
  51. Ladapo JA, Hoffman U, Bamberg F et al. Cost-effectiveness of coronary MDCT in the triage of patients with acute chest pain. American Journal of Roentgenology 2008; 191: 455 – 463.
  52. Leber A, et al. Accuracy of Multidetector Spiral Computed Tomography in Identifying and Differentiating the Composition of Coronary Atherosclerotic Plaques, Journal of the American College of Cardiology, Vol. 43, No. 7:1241 – 1247, 2004.
  53. Leber AW, Becker A, Knez A. Accuracy of 64-slice computed tomography to classify and quantify plaque volumes in the proximal coronary system: a comparative study using intravascular ultrasound. Journal of the American College of Cardiology 2006; 47(3): 672 – 892.
  54. Levin DC, Parker L, Sunshine JH et al. Cardiovascular imaging: who does it and how important is it to the practice of radiology? American Journal of Roentgenology; 178: 303 – 306.
  55. Maruyama T, et al. Comparison of Visibility and Diagnostic Capability of Noninvasive Coronary Angiography by Eight-Slice Multidetector-Row Computed Tomography Versus Conventional Coronary Angiography, The American Journal of Cardiology, Vol. 93 No. 5, 03/01/04.
  56. Matsumoto N, Sato Y, Yoda S et al. Prognostic value of non-obstructive CT low-dense coronary artery plaques detected by multislice computed tomography 2007; 71(12): 1898 – 1903.
  57. Meijboom WB, Meijs MF, Schuijf JD et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. Journal of the American College of Cardiology 2008; 52(25): 2135 – 2144.
  58. Meijboom WB, van Mieghem CA, Mollet NR et al. 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. Journal of the American College of Cardiology 2007; 50(15): 1469 – 1475.
  59. Meijer AB, O YL, Geleijns J et al. Meta-analysis of 40-and 64-MDCT angiography for assessing coronary artery stenosis. American Journal of Roentgenology 2008; 191(6): 1667 – 1675.
  60. Meyer TS, Martinoff S, Hadamitzky M et al. Improved noninvasive assessment of coronary artery bypass grafts with 64-slice computed tomographic angiography in an unselected patient population. Journal of the American College of Cardiology 2007; 49(9): 946 – 950.
  61. Miller JM, Rochitte CE, Dewey M et al. Diagnostic performance of coronary angiography by 64-row CT. The New England Journal of Medicine 2008; 359(22): 2324 – 2336.
  62. Min JK. Coronary CTA versus cardiac catheterization: where do we stand today? Supplement To Applied Radiology 2006, 32 – 40.
  63. Mollet N, et al. Multislice Spiral Computed Tomograpy Coronary Angiography in Patients with Stable Angina Pectoris. Journal of the American College of Cardiology, Vol. 43, No. 12:2265 – 2270, 2004.
  64. Mowatt G, Cook JA, Hillis GS et al. 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. British Cardiac Society 2008; 94(11): 1386 – 1393.
  65. National Imaging Associates, Inc. CT Coronary Angiography (CCTA) Clinical Guidelines, 05/12
  66. Nikolaou K, Knez A, Rist C et al. Accuracy of 64-MDCT in the diagnosis of ischemic heart disease. American Journal of Roentgenology 2006; 187: 111 – 117.
  67. Ong TK, Chin SP, Liew Ck et al. Accuracy of 64-row multidetector computed tomography in detecting coronary artery disease in 134 symptomatic patients: influence of calcification. American Heart Journal 2006; 151(6): 1323. el-6.
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  73. Raff GL, Gallagher MJ, O’Neil WW et al. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. Journal of the American College of Cardiology 2005; 46(3): 552-557.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/24/12.

GUIDELINE UPDATE INFORMATION:

12/15/04

New Medical Coverage Guideline.

02/15/06

Revised investigational rationales deleted “a lack of” and change to “insufficient evidence”. Added screening for coronary artery disease (CAD) to when services are not covered. Added the word “evaluation” to coronary artery bypass graft patency and coronary artery aneurysm (when services are not covered). Added the wording “delineation of” to congenital coronary artery anomaly (when services are not covered). Added delineation of coronary artery anatomy to when services are not covered. Added CPT “T” codes: 0146T, 0147T, 0148T, and 0149T (tag investigational-MPF), and updated references. Revised name of MCG, deleted “for coronary artery evaluation” – Computed Tomographic Angiography (CTA).

04/01/06

HCPCS update, deleted S8093.

05/15/06

Added 0145T, 0150T, and 0151T.

03/15/07

Scheduled review. Added “for Coronary Artery Evaluation” to the title of the MCG. Revised the descriptor section, to update the information regarding computed tomographic angiography (CTA) and multidetector row helical CT (MDCT) and multislice CT (MSCT). Revised WHEN SERVICES ARE COVERED, added coverage statement for evaluation for evaluation of anomalous coronary arteries. Revised WHEN SERVICES ARE NOT COVERED, added investigational statement for all other indications. Deleted CPT code: 0145T, 0150T, and 0151T from the BILLING/CODING INFORMATION section. Added program exception for Medicare Advantage products. Added cardiac computed tomography (CCT) to OTHER section, and updated references.

06/15/07

Reformatted guideline.

07/01/07

Updated Program Exception section.

01/01/08

HCPCS update. Revised 0146T, 0147T, 0148T, and 0149T descriptor.

01/21/08

Updated Program Exceptions.

03/15/08

Scheduled review. Revised position statement. Updated billing/coding information section, added ICD-9 diagnosis coronary artery anomaly 746.85. Updated reimbursement information section, and updated references.

11/05/08

Updated Program Exceptions.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

06/25/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Annual HCPCS coding update: deleted 0146T, 0147T, 0148T, 0149T, and 0151T; added 75572, 75573, and 75574. Revised BCBSF Radiology Management program exception section, and updated the references.

05/15/10

Updated guideline name, deleted “for coronary artery evaluation”. Revised description. Expanded medical necessity indications; added criteria, and updated references.

06/15/11

Annual review: maintain position statements. Updated references.

10/01/11

Revision; formatting changes.

06/15/12

Scheduled review; added indications for computed tomography, heart. Deleted ICD-9 codes (Medicare). Updated references.

12/15/12

Updated Medicare program exception. Added Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02 to related guidelines section.

01/01/14

Review/revision. Added “of the heart and coronary arteries” to computed tomographic angiography (CTA).

Date Printed: August 23, 2017: 01:36 PM