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04-70450-03

Original Effective Date: 12/15/04

Reviewed: 04/26/18

Revised: 05/15/18

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:

Coronary computed tomographic angiography (CTA/CCTA) is a noninvasive cardiac imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging CT equipment to obtain detailed volumetric images of blood vessels. CTA can image blood vessels throughout the body. Imaging of the coronary vasculature requires shorter image acquisition times to avoid blurring from the motion of the beating heart. The advanced spatial and temporal resolution features of these CT scanning systems offer a unique method for imaging the coronary arteries and the heart in motion, and for detecting arterial calcification that contributes to coronary artery disease.

The tables in this guideline correlate with the American College of Cardiology Foundation (ACCF) and collaborating organizations* cardiac imaging appropriate use criteria (by indication). The indications are scored as follows: score 7 to 9; appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication), score 4 to 6; uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication), and score 1 to 3; inappropriate test for specific indication (test is not generally acceptable and is not a reasonable approach for the indication). In addition to the appropriate use for cardiac imaging additional factors should be taken into consideration (e.g., impact of the imaging study on clinical decision making when combined with clinical judgment and risks (radiation or contrast exposure)).

Where the CTA/CCTA is the preferred test based upon the indication, the Appropriate Use Score will be in the upper range such as noted with indication # 46, Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels.

*Society of Cardiovascular Computed Tomography (SCCT), American College of Radiology (ACR), American Heart Association (AHA), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), North American Society for Cardiovascular Imaging (NASCI), Society for Cardiovascular Angiography and Intervention (SCAI), Society for Cardiovascular Magnetic Resonance (SCMR)

POSITION STATEMENT:

Computed tomographic angiography (CTA/CCTA) meets the definition of medical necessity when the member meets appropriate use criteria, for indications with an appropriate use score of 4 to 9 (A= Appropriate (7-9), U= Uncertain (4-6)) as noted below.

Appropriate Use Criteria

*American College of Cardiology Foundation (ACCF) and collaborating organizations Appropriate Use Criteria: Appropriate Use Score (A = Appropriate (7-9)); Test is generally acceptable and is a reasonable approach for the indication.

Appropriate Indications

CTA

Indication # with Appropriate Use Score

A=Appropriate (7-9)

Indications

(Refer to reimbursement information section.)

Detection of CAD in Symptomatic Patients without Known Heart Disease

Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent

1 A (7)

Intermediate pretest probability of CAD AND

ECG uninterpretable AND

Able to exercise

2 A (7)

Low pretest probability of CAD

ECG uninterpretable or unable to exercise

2 A (8)

Intermediate pretest probability of CAD

ECG uninterpretable or unable to exercise

Acute Symptoms With Suspicion of ACS (Urgent Presentation) after Standard Evaluation Has Not Resulted in an Actionable Diagnosis

5 A (7-9)

If one of the following apply:

Acute chest pain of uncertain cause (differential diagnosis includes pulmonary embolism, aortic dissection, and ACS ["triple rule out"])

Equivocal diagnosis due to single troponin elevation without additional evidence of ACS

Equivocal diagnosis with ischemic symptoms resolved hours before testing

Low-to-intermediate likelihood of ACS based upon TIMI RISK Score = 0, with early high sensitivity troponin negative

Low-to-intermediate likelihood of ACS based upon normal/nonischemic initial EKG and normal initial troponin

Serial EKGs and troponins negative or if either is borderline for NSTEMI/ACS

Detection of CAD in Symptomatic Patients Without Known Heart Disease

SymptomaticAcute Symptoms With Suspicion of ACS (Urgent Presentation), when the History Reveals a Particular Pretest Probability

6 A (7)

Low pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

Normal ECG and cardiac biomarkers (troponin and CPK/CPK-MB)

6 A (7)

Intermediate pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

Normal ECG and cardiac biomarkers (troponin and CPK/CPK-MB)

7 A (7)

Low pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

ECG uninterpretable

7 A (7)

Intermediate pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

ECG uninterpretable

8 A (7)

Low pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

Nondiagnostic ECG or equivocal cardiac biomarkers

8 A (7)

Intermediate pretest probability

Acute symptoms, possibly representing an ischemic equivalent AND

Nondiagnostic ECG or equivocal cardiac biomarkers

Detection of CAD in Other Clinical Scenarios-New—Onset or Newly Diagnosed Clinical HF and No Prior CAD

13 A (7-9)

Reduced left ventricular ejection fraction (<40% EF), when invasive coronary arteriography is not the preferred method of evaluation

Low pretest probability of CAD

Detection of CAD in Other Clinical ScenariosPreoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery or Noncoronary Intervention

15 A (7-9)

If all the following apply:

Coronary evaluation before thoracoabdominal aortic surgery

Member has less than a 4 MET functional capacity

Member has one peri-operative risk factor

No coronary evaluation (invasive or non-invasive) within the past year

If invasive coronary arteriography is preferable, then CCTA is not appropriate

Alternatively, without the need for the above criteria, patient would be a candidate for CCTA at the time of a preoperative evaluation if indications unrelated to the surgery were well documented in the clinical record

Use of CTA in the Setting of Prior Test ResultsPrior ECG or ECG Exercise Testing

20 A (7)

Normal ECG exercise test

Continued symptoms

21 A (7)

Prior ECG exercise AND

Intermediate mortality risk (based upon Duke Treadmill Score)

Use of CTA in the Setting of Prior Test Results-Sequential Testing After Stress Imaging Procedures

22 A (8)

Discordant ECG exercise and imaging results

23 A (8)

Prior stress ECG or stress imaging results: equivocal for ischemia

Use of CTA in the Setting of Prior Test ResultsEvaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study

29 A (7-9)

Previous stress ECG or stress imaging study abnormal when a noninvasive approach is preferable to proceeding to invasive coronary arteriography (unclear nature of symptoms, mildly abnormal or borderline EKG stress test or stress with echocardiogram/MPI, CK, dye allergy, etc.)

Previous stress ECG study normal when a noninvasive approach is preferable to proceeding to invasive coronary arteriography (unclear nature of symptoms, mildly abnormal or borderline EKG stress test or stress with echocardiogram/MPI, CKD, dye allergy, etc.)

Previous stress imaging study normal within the past 2 years and currently compelling coronary history or symptoms should be considered appropriate indication for a CCTA, particularly if there are reasons to avoid cardiac catheterization (CKD, dye allergy, etc.), unless invasive coronary arteriography is strongly indicated (e.g. compelling presentation of moderate or high risk unstable angina).

Evaluation of Cardiac Structure and FunctionAdult Congenital Heart Disease

46 A (9)

Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels. This includes long term follow-up of Kawasaki disease for aneurysm formation.

Note: For “anomalies of coronary arterial vessels” CCTA preferred and for “other thoracic arteriovenous vessels” Heart CT preferred .

60 A (8)

Localization of coronary bypass grafts and other retrosternal anatomy

Prior to preoperative chest or cardiac surgery

For “localization of coronary bypass grafts” CCTA preferred and for “other retrosternal anatomy” Heart CT preferred .

Uncertain Indications

*American College of Cardiology Foundation (ACCF) and collaborating organizations Appropriate Use Criteria: Uncertain

Use Score (U= Uncertain (4-6)); Test may be generally acceptable and may be a reasonable approach for the indication.

CTA

Indication # with Appropriate Use Score

U= Uncertain (4-6)

Indications

(Refer to reimbursement information section.)

Detection of CAD in Symptomatic Patients Without Known Heart Disease

Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent

1 U (5)

Low pretest probability of CAD

ECG interpretable and able to exercise

2 U (4)

High pretest probability of CAD

ECG uninterpretable or unable to exercise

Detection of CAD in Symptomatic Patients Without Known Heart Disease

Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation)

4 U (6)

Persistent ECG ST-segment elevation following exclusion of MI by invasive coronary arteriography

5 U (4-6)

Acute chest pain of uncertain cause (differential diagnosis includes pulmonary embolism, aortic dissection, and ACS [“triple rule out”])

Diagnosis unequivocally positive for ACS, but this category should be reserved for patients in whom invasive coronary arteriography would be considered at least relatively contraindicated

6 U (4)

Acute symptoms, possibly representing an ischemcic equivalent

Normal ECG and cardiac biomarkers (troponin and CPK/CPK-MB)

High pretest probability of CAD

7 U (4)

Acute symptoms, possibly representing an ischemcic equivalent

ECG uninterpretable

High pretest probability of CAD

8 U (4)

Acute symptoms, possibly representing an ischemcic equivalent

Nondiagnostic ECG or equivocal cardiac biomarkers

High pretest probability of CAD

Additional CAD/Risk Assessment, Based Upon Pre-existing Global Risk, in Asymptomatic Individuals Without Known CAD

10 U (4-6)

Intermediate global CAD Risk (10-20%, or 6-20% in women and younger men)

If all the following apply:

Risk assessment in asymptomatic patients (not for diagnosis in symptomatic patients)

No known CAD

Result could change management of coronary risk

Coronary CTA with Contrast in the Asymptomatic Individual

10 U (4-6)

High global CAD Risk (>20%)

If all the following apply:

Risk assessment in asymptomatic members

No known CAD

Not a candidate for EKG stress testing alone due to inability to

exercise or an uninterpretable EKG

Not a candidate for stress echocardiography due to inability to exercise

Result could change management of coronary risk

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA Following Heart Transplantation

12 U (6)

Routine evaluation of coronary arteries for transplant vasculopathy

Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery or Noncoronary Intervention

15 U (6)

Coronary evaluation before noncoronary cardiac surgery

Low pretest probability of CAD

15 a U (5)

Prior to TAVR as an alternative to coronary arteriography

Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation

17 U (4-6)

Any one of the following:

Exercise induced or nonsustained ventricular tachycardia

Ventricular fibrillation

Sustained VT

Frequent PVCs (>30/hr)

Prior to initiation of antiarrhythmic therapy in high global risk (CAD) members

18 U (4-6)

Syncope

Intermediate and High global CAD risk** initial evaluation includes echocardiogram

Detection of CAD in Other Clinical Scenarios—Elevated Troponin of Uncertain Clinical Significance

19 U (6)

Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD

Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stess Imaging Procedures— Prior ECG or ECG Exercise Testing

23 U (4-6)

Abnormal rest ECG (highly concerning for ischemia, without clear indication for invasive coronary arteriography)

Left bundle branch block, when the history, physical examination, and/or noninvasive ejection fraction together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress imaging (MPI or echocardiography)

Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures

23 U (6)

Prior stress ECG or stress imaging results: mild ischemia

Risk Assessment Post revascularization (PCI or CABG)Symptomatic (Ischemic Equivalent) Post Coronary Revascularization

39 U (4-6)

Evaluation of graft patency after CABG or evaluation post percutaneous coronary intervention, with documentation of symptomatic presentation (indications for CCTA, if it could affect management)

Asymptomatic—Post Coronary Revascularization

42 U (4-6)

Prior left main coronary stent

Other Indications:

Computed tomographic angiography (CTA) may be appropriately used when evaluating chest pain syndromes with low to intermediate risk CAD profiles in an emergency room or observation unit.

Computed tomographic angiography (CTA) does not meet the definition of medical necessity for the following indications unless the member meets the above criteria** for indications with an appropriate use score of 4 to 9 (A= Appropriate (7-9), U= Uncertain (4-6) OR any ONE of the following:

Contraindications to beta blockers used to slow heart rate during procedure.

Acute chest pain/angina (Member with acute angina/chest pain may need to go directly to

catheterization; requires Medical Director review).

Pre-operative request for non-cardiac surgery.

Significant premature ventricular contractions, significant frequent atrial fibrillation, or relative

contraindication to CTA.

Inappropriate Indications

*American College of Cardiology Foundation (ACCF) and collaborating organizations Appropriate Use Criteria: Inappropriate

Use Score (I = Inappropriate (1-3)); Test is not generally acceptable and is not a reasonable approach for the indication.

CTA

Indication # with Appropriate Use Score

I= Inappropriate (1-3)

Indications

(Refer to reimbursement information section.)

Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic Nonacute Symptoms Possibly Representing an Ischemic Equivalent

1 I (3)

High pretest probability of CAD

ECG interpretable and able to exercise

Acute Symptoms With Suspicion of ACS (Urgent Presentation)

3 I (1)

Definite MI

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CADNoncontrast CT for CCS

10 I (2)

Low global CHD risk estimate

Coronary CTA

11 I (2)

Low or intermediate global CHD risk estimate

Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery

15 I (3)

High pretest probability of CAD

Coronary evaluation before noncoronary cardiac surgery

Arrhythmias—Etiology Unclear After Initial Evaluation

16 I (2)

New onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging

Arrhythmias—Etiology Unclear After Initial Evaluation

17 I (1-3)

Any one of the following:

Infrequent PVCs

New Onset atrial fibrillation

18 I (1-3)

Syncope

Low Global CAD risk

Use of CTA in the Setting of Prior Test Results

ECG Exercise Testing

21 I (2)

Prior ECG exercise testing

Duke Treadmill Score—low risk findings

22 I (3)

Prior ECG exercise testing

Duke Treadmill Scorehigh risk findings

Sequential Testing After Stress Imaging Procedures

23 I (2)

Stress imaging results: moderate or severe ischemia

Prior Coronary Calcium Score (CCS)

25 I (2)

Positive coronary calcium score (CCS) >2 years ago

Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress

Imaging or Coronary Angiography

27 I (2)

No known CAD

Last study done <2 years ago

27 I (3)

No known CAD

Last study done 2 years ago

28 I (2)

Known CAD

Last study done <2 years ago

28 I (3)

Known CAD

Last study done 2 years ago

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Low Risk Surgery

30 I (1)

Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate Risk Surgery

31 I (2)

No clinical risk predictors

32 I (2)

Functional capacity 4 METs

34 I (1)

Asymptomatic <1 y following a normal coronary angiogram, stress test, or a coronary revascularization procedure

Vascular Surgery

35 I (2)

No clinical risk predictors

36 I (2)

Functional capacity ≥ 4 METs

38 I (2)

Asymptomatic <1 y following a normal coronary angiogram, stress test, or a coronary revascularization procedure

Risk Assessment Post revascularization (PCI or CABG)—(Ischemic Equivalent)

40 I (3)

Prior coronary stent with stent diameter <3 mm or not known

Asymptomatic CABG

42 I (2)

Prior coronary bypass surgery <5 years ago

Asymptomatic—Prior Coronary Stenting

44 I (3)

Prior coronary stent with stent diameter <3 mm or not known

45 I (3)

Prior coronary stent with stent diameter 3 mm

Less than 2 years after PCI

Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function

48 I (2)

Initial evaluation of left ventricular function

Following acute MI or in HF patients

Evaluation of Intra and Extracardiac Structures

55 I (3)

Initial evaluation of cardiac mass (suspected tumor or thrombus)

BILLING/CODING INFORMATION:

CPT Coding:

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:

Anginal or Ischemic Equivalent

Development of an anginal equivalent (e.g. shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons to suspect that symptoms other than chest discomfort are not due to other organ systems (e.g. dyspnea due to lung disease, fatigue due to anemia, etc.), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope by itself is generally not considered an anginal equivalent, and is handled under a separate category in this guideline.

Exercise Treadmill Testing

Exercise Treadmill Testing (ETT) is the appropriate first line test in most patients with suspected CAD. In appropriately selected patients the test provides adequate sensitivity and specificity with regard to diagnosis and prognostication. There are patients in whom the test is not the best choice, for example those with resting ECG abnormalities, inability to exercise and perhaps diabetes. Also of note from an operational standpoint the test does not require pre-authorization.

An uninterpretable baseline EKG includes:

Abnormalities of ST segment depression of 0.1 mV (1 mm with conventional calibration) or more

Ischemic looking T wave inversions of at least 0.25 mV (2.5 mm with conventional calibration)

EKG findings of probable or definite LVH, WPW, a ventricular paced rhythm, or left bundle branch block

Digitalis use or hypokalemia

Resting HR under 50 bpm on a beta blocker and an anticipated suboptimal workload (e.g. ratepressure product less than 20-25K)

Prior false positive stress EKG

Once the presence of symptoms (Typical Angina/Atypical Angina/Non angina chest pain/Asymptomatic) is determined, the pretest probabilities of CAD can be calculated from the risk algorithms as follows:

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%

CAD Risk:

It is assumed that clinicians will use current standard methods of global risk assessment such as those presented in the National Heart, Lung, and Blood Institute report on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) or similar national guidelines. CAD risk refers to 10-year risk for any hard cardiac event (e.g., myocardial infarction or CAD death).

Low global CAD risk

Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.

Intermediate global CAD risk

Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a 10-year absolute CAD risk range of 10% to 20%. Among women and younger age men, an expanded intermediate risk range of 6% to 20% may be appropriate.

High global CAD risk

Defined by the age-specific risk level that is above average. In general, high risk will correlate with a 10-year absolute CAD risk of >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can also define high risk.

Duke Treadmill Score

The equation for calculating the Duke treadmill score (DTS) is, DTS = exercise time in minutes - (5 * ST deviation in mm or 0.1 mV increments) - (4 * exercise angina score), with angina score being 0 = none, 1 = non limiting, and 2 = exercise-limiting. The score typically ranges from -25 to +15. These values correspond to low-risk (with a score of >/= +5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of </= -11) categories.

Determinants of a 4 Metabolic Equivalents (METs) Functional Capacity:

Examples of activities:

<4 METs:

Slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at approximately 2 mph to 3 mph

>4 METs:

Climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house

If a patient has not had a recent exercise test before noncardiac surgery, functional status can usually be estimated from activities of daily living. Functional capacity is often expressed in terms of metabolic equivalents (METs), where 1 MET is the resting or basal oxygen consumption of a 40–year old, 70-kg man. In the perioperative literature, functional capacity is classified as excellent (>10 METs), good (7 METs to 10 METs), moderate (4 METs to 6 METs), poor (<4 METs), or unknown. Perioperative cardiac and long-term risks are increased in patients unable to perform 4 METs of work during daily activities. Examples of activities associated with <4 METs are slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at approximately 2 mph to 3 mph. Examples of activities associated with >4 METs are climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house. Source: Fleisher LA, Fleischmann KE, Auerbach AD et al. ACC/AHA Clinical Practice Guideline 2014 ACC/AHA Guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130: e278-e333

Characterization of Unstable Angina

Three Principal Presentations of Unstable Angina (as defined within a two week timeframe)

Class

Presentation

Rest angina*

Angina occurring at rest and prolonged, usually > 20 minutes

New-onset angina

New-onset angina of at least CCS Class III severity

Increasing angina

Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by ≥ 1 CCS class to at least CCS Class III severity)

*Patients with NSTEMI usually present with angina at rest.

Abbreviation: CCS= Candian Cardiovascular Society

Adapted from: Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American Colleg of Cardiology 2007; 50(7): 652-726

Table 3

  1. that Signs and Symptoms Indicate an Acute Coronary Syndrome (ACS Secondary to coronary artery disease (CAD))

Feature

High Likelihood-Any of the following:

Intermediate likelihood

Absence of high-likelihood features and presence of any of the following:

Low likelihood

Absence of high-or intermediate-likelihood features but may have:

History

Chest or left arm pain or discomfort as chief symptom reproducing previously documented angina

Known history of CAD, including MI

Chest or left arm pain or discomfort as chief symptom

Age ≥ 70 years

Male sex

Diabetes

Probable ischemic symptoms in absence of any of the intermediate likelihood characteristics

Recent cocaine use

Examination

Transient MR murmur, hypotension, diaphoresis, pulmonary edema, or rales

Extracardiac vascular disease

Chest discomfort reproduced by palpation

T-wave flattening or inversion <1 mm in leads with dominant R waves

Normal ECG tracing

ECG

New, or presumably new, transient ST-segment deviation (≥1 mm) or T-wave inversion in multiple precordial leads

Fixed Q waves

ST depression of 0.5-1.0 mm or T-wave inversion >1.0 mm

 

Cardiac markers

Elevated cardiac TnI, TnT, or CK-MB levels

Normal

Normal

ACS = acute coronary syndrome; CAD = coronary artery disease; CK-MB = muscle and brain fraction of creatine kinase; ECG = electrocardiography; MI =myocardial infarction; MR = mitral regurgitation; TnI = troponin I; TnT = troponin T.

Adapted from: Kumar A, Cannon CP. Acute Coronary Syndromes: Diagnosis and Management, Part I. Mayo Clinic Proceedings 2009; 84(10): 917-938

Table 4

  1. Term Risk of Death or Nonfatal Myocardial Infarction (MI) in Acute Coronary Syndrome (ACS)

Feature

High risk-At least 1 of the following features must be present:

Intermediate risk-No high-risk feature, but must have 1 of the following:

Low risk-No high-or intermediate-risk feature but may have any of the following

History

Accelerating tempo of ischemic symptoms in preceding 48 hour

Previous MI, peripheral or cerebrovascular disease, or CABG; previous aspirin use

 

Character of pain

Prolong ongoing (>20 min) resting pain

Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD

Rest angina (>20 min) or relieved with rest or sublingual nitroglycerin

Nocturnal angina

New-onset or progressive CCS class III or IV angina in the past 2 weeks without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD

Increased angina frequency, severity, or duration

Angina provoked at a lower threshold

New-onset angina with onset 2 weeks to 2 months before presentation

Clinical findings

Pulmonary edema, most likely because of ischemia

New or worsening MR murmur S3 or new/worsening rales

Hypotension, bradycardia, tachycardia

Age ≥75 years

Age ≥70 years

 

ECG

Angina at rest with transient ST-segment changes >0.5 mm

Bundle branch block, new or presumed new

Sustained ventricular tachycardia

T wave changes

Pathologic Q waves or resting ST-depression <1 mm in multiple lead groups (anterior, inferior, lateral)

Normal or unchanged findings on ECG

Cardiac markers

Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT, or TnI >0.1 ng/mL)

Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 ng/mL)

Normal

CABG= coronary artery bypass graft; CAD= coronary artery disease; CCS= Canadian Cardiovascular Society; CK-MB= muscle brain fraction of creatine kinase; ECG= electrocardiography; MI= myocardial infarction; MR= mitral regurgitation; NSTEMI= non-ST-elevation myocardial infarction

Adapted from: Kumar A, Cannon CP. Acute Coronary Syndromes: Diagnosis and Management, Part I. Mayo Clinic Proceedings 2009; 84(10): 917-938

The TIMI Risk Score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables: age ≥65 years, at least 3 risk factors for CAD, prior coronary stenosis of ≥50%, ST-segment deviation on ECG presentation, at least 2 anginal events in prior 24 hours, use of aspirin in prior 7 days, and elevated serum cardiac biomarkers Low-Risk TIMI Score: TIMI score <2; High-Risk TIMI Score: TIMI score ≥2. A low risk TIMI score might still warrant invasive coronary arteriography, when other features, such as symptoms, are compelling.

Equivocal and Mild Ischemia

Equivocal for ischemia on stress testing can be defined as a post-test probability of significant coronary narrowing of approximately 20-50%, such that a decision to proceed with invasive coronary arteriography is not clear, and additional non-invasive testing would be expected to frequently enable a greater or lesser probability of significant coronary artery disease.

Mild ischemia on stress testing can be defined as a stress EKG with a Duke score above 4 without stress imaging, a stress EKG response that is of borderline positivity, stress echocardiography that shows <=2 segments of myocardial hypokinesia, or myocardial perfusion imaging with <5% myocardium at risk, such that a decision to proceed with invasive coronary arteriography is not clear, and additional noninvasive testing would be expected to frequently enable a greater or lesser probability of significant coronary artery disease.

Online cardiac risk calculator and assessment tools:

The links for the online cardiac risk calculator and assessment tools are to an outside source and is provided for your convenience. Use of the links and related calculator and assessment tools are subject to the terms and conditions of the website and is not warranted, maintained or affiliated with Florida Blue.

Framingham Risk Score Calculator

https://www.framinghamheartstudy.org/

http://tools.acc.org/ASCVD-Risk-Estimator/

Reynolds Risk Score

http://www.reynoldsriskscore.org/

Pooled Cohort Risk Assessment Equations

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

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)

Abbreviations

ACS = acute coronary syndrome

CABG = coronary artery bypass grafting surgery

CAD = coronary artery disease

CCS = coronary calcium score

CHD = coronary heart disease

CCTA = coronary computed tomographic angiography

CKD = chronic kidney disease

CPK = creatine phosphokinase

CPK-MB = creatine kinase-muscle/brain

CT = computed tomography

CTA = computed tomography angiography

ECG/EKG = electrocardiogram

HF = heart failure

MET = estimated metabolic equivalent of exercise

MI = myocardial infarction

MPI = myocardial Perfusion Imaging

NSTEMI = non-ST-elevation myocardial infarction

PCI = percutaneous coronary intervention

PVC = premature ventricular contraction

SE = stress echocardiogram

TIMI = thrombolysis in myocardial infarction

TTE = transthoracic echocardiography

TAVR = transcatheter aortic valve replacement

VT = ventricular tachycardia

REFERENCES:

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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/26/18.

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).

05/15/18

Revision; revised position statement. Updated references.

Date Printed: May 21, 2018: 08:28 PM