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Date Printed: May 27, 2018: 07:42 PM

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04-70450-26

Original Effective Date: 05/15/18

Reviewed: 04/26/18

Revised: 00/00/00

Subject: Computed Tomography (CT) 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 tomography (CT) heart (cardiac CT) can be used to evaluate the anatomy and pathology of the pericardium and cardiac chambers and assessment of the central great vessels and heart function, including the cardiac valves. Cardiac CT is also useful in detecting and characterizing cardiac and pericardial disorders, such as masses and pericardial fluid. CT is a form of medical imaging that involves the exposure of patients to ionizing radiation. CT should only be performed under the supervision of a physician with training in radiation protection to optimize examination safety. Radiation exposure should be taken into account when considering the use of this technology. This guideline addresses the use of heart CT for characterization of congenital heart disease, characterization of cardiac masses, diagnosis of pericardial diseases, and pre-operative coronary vein mapping in the outpatient setting.

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)).

For indications in which there are one or more alternative tests with an appropriate use score rating (appropriate, uncertain) noted, for example indication #52 (Assessment of myocardial viability, prior to myocardial revascularization for ischemic left ventricular systolic dysfunction and other imaging modalities are inadequate or contraindicated), additional factors should be considered when determining the preferred test (Stress Echocardiogram if there are no contraindications).

Where indicated as alternative tests, TTE (transthoracic echocardiography) and SE (Stress echocardiography) are a better choice, where possible, because of avoidance of radiation exposure. Heart MRI can be considered as an alternative, especially in young patients, where recurrent examinations may be necessary.

*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:

Cardiac computed tomography (heart CT) meets the definition of medically necessity when the member meets the appropriate use criteria*, for indications with an appropriate use score of 4-9 (A= Appropriate (7-9), U= Uncertain (4-6)) as noted below.

APPROPRIATE USE INDICATIONS

*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 and Uncertain

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

Heart CT

# with Appropriate Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(Refer to reimbursement information section.)

Evaluation of Cardiac Structure and Function—Adult Congenital Heart Disease

46 A (9)

• Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels*

*For anomalies of coronary arterial vessels, CCTA preferred.

*For other thoracic arteriovenous vessels, heart CT preferred.

• For evaluation of structural heart disease, such as TGA when MRI might be preferable but cannot be performed

47 A (8)

• Further assessment of complex adult congenital heart disease after confirmation by TTE echocardiogram

48 A (7)

• Evaluation of left ventricular function

• Following acute MI or in HF members

• Inadequate images from other noninvasive methods

50 A (7)

• Quantitative evaluation of right ventricular function

51 A (7)

• Assessment of right ventricular morphology

• Suspected arrhythmogenic right ventricular dysplasia

52 U (5)

• Assessment of myocardial viability

• Prior to myocardial revascularization for ischemic left ventricular systolic dysfunction

• Other imaging modalities are inadequate or contraindicated

Evaluation of Cardiac Structure and Function—Evaluation of Intra and Extracardiac Sturctures

53 A (8)

• Characterization of native cardiac valves

• Suspected clinically significant valvular dysfunction

• Inadequate images from other noninvasive methods

• Re-evaluation (<1 year) of the size and morphology of the aortic sinuses and ascending aorta in members with a bicuspid AV and ascending aortic diameter >4 cm with 1 of the following:

• Aortic diameter >4.5 cm

• Rapid rate of change in aortic diameter

• Family history (first-degree relative) of aortic dissection.

• Alternative imaging modality: CMR A (8), TTE A (7)

54 A (8)

• Characterization of prosthetic cardiac values

• For assessment of prosthetic valve thrombosis for suspected clinically significant valvular dysfunction

• Inadequate images from other noninvasive methods

55 U (6)

• Severe TR and suboptimal TTE images, for assessment of RV systolic function and systolic and diastolic volumes

• Alternative imaging modality is CMR A (8)

56 A (8)

• Evaluation of cardiac mass (suspected tumor or thrombus)

• Inadequate images from other noninvasive methods

57 A (8)

• Evaluation of pericardial anatomy

58 A (8)

• Evaluation of pulmonary vein anatomy

• Prior to radiofrequency ablation for atrial fibrillation

59 A (8)

• Noninvasive coronary vein mapping

• Prior to placement of biventricular pacemaker

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.

*For other retrosternal anatomy, heart CT preferred.

Pre-operative or Pre-Procedural Evaluation

Pre-operative evaluation prior to structural heart interventions, such as transcatheter aortic valve replacement (TAVR).

For indications in which there are one or more alternative tests with an appropriate use score 4 to 9 (A= Appropriate (7-9), U= Uncertain (4-6)), (for example indication #52) then additional factors should be considered when determining the preferred test (stress echocardiogram if there are no contraindications).

Cardiac computed tomography (heart CT) does not meet the definition of medical necessity for the following unless the member meets the above appropriate use criteria for indications with an appropriate use score of 4 to 9 (A= Appropriate (7-9), U= Uncertain (4-6) OR for any one or more of the following:

• For same imaging test less than six weeks apart unless specific guideline criteria states otherwise.

• For different imaging tests, such as CT and MRI or same anatomical structure less than six weeks apart without medical review to evaluate medical necessity.

• For re-imaging of repeat or poor quality studies.

• For imaging of pediatric members twelve years old and younger.

Contraindications:

There is insufficient data to support the routine use of cardiac computed tomography (heart CT) for following:

• As the first test in evaluating symptomatic member (e.g., chest pain).

• To evaluate chest pain in an intermediate or high risk member when a stress test (exercise treadmill, stress echocardiography, MPI, cardiac MRI, cardiac PET) is clearly positive or negative.

• Preoperative assessment for non-cardiac nonvascular surgery.

• Preoperative imaging prior to robotic surgery (e.g., to visualize the entire aorta).

• Evaluation of left ventricular function following myocardial infarction or in chronic heart failure.

• Myocardial perfusion and viability studies.

• Evaluation of members with postoperative native or prosthetic cardiac valves who have technically limited echocardiograms, MRI or TEE.

BILLING/CODING INFORMATION:

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)

REIMBURSEMENT INFORMATION:

ECG–Uninterpretabl

Refers to electrocardiograms (ECGs) with resting ST-segment depression (≥0.10 mV), complete left bundle-branch block (LBBB,) pre-excitation (Wolff-Parkinson-White syndrome), or paced rhythm.

Acute Coronary Syndrome (ACS)

Patients with an ACS include those whose clinical presentations cover the following range of diagnoses: unstable angina, myocardial infarction without ST-segment elevation (NSTEMI), and myocardial infarction with ST-segment elevation (STEMI).

Pretest Probability of CAD for Symptomatic (Ischemic Equivalent) Patients

Angina: As defined by the ACC/AHA Guidelines on Exercise Testing

Typical Angina (Definite): Defined as:

• Substernal chest pain or an ischemic equivalent discomfort that is:

• Provoked by exertion or emotional stress; and

• Relieved by rest and/or nitroglycerin.

Atypical Angina (Probable): Defined as:

Chest pain or discomfort that lacks 1 of the characteristics of definite or typical angina.

Non-Anginal Chest Pain: Defined as:

Chest pain or discomfort that meets 1 or none of the typical angina characteristics.

Once the presence of symptoms (typical angina, atypical angina, nonanginal chest pain, asymptomatic) is determined, the pretest probabilities of coronary artery disease (CAD) can be calculated from the risk algorithms as follows:

Pretest Probability of CAD by Age, Gender, and Symptoms

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

Very low: Less than 5% pre-test probability of CAD

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

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

High: Greater than 90% pre-test probability of CAD

Global 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.

Perioperative Clinical Risk Predictors (As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery)

• History of ischemic heart disease

• History of compensated or prior heart failure

• History if cerebrovascular disease

• Diabetes mellitus (requiring insulin)

• Renal insufficiency (creatinine > 2.0)

Surgical Risk Categories (As defined by the ACC/AHA guidelines update for perioperative cardiovascular evaluation of non-cardiac surgery)

High-Risk Surgery—cardiac death or MI greater than 5%

• Emergent major operations (particularly in the elderly), aortic and peripheral vascular surgery, prolonged surgical procedures associated with large fluid shifts and/or blood loss.

Intermediate-Risk Surgery—cardiac death or MI = 1% to 5%

• Carotid endarterectomy, head and neck surgery, surgery of the chest or abdomen, orthopedic surgery, prostate surgery.

Low-Risk Surgery—cardiac death or MI less than 1%

• Endoscopic procedures, superficial procedures, cataract surgery, breast surgery.

Request for a follow-up study

A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

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 tomography (heart CT).

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

Radiology reason for study

18785-6

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

Radiology comparison study-date and time

18779-9

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

Radiology comparison study observation

18834-2

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

Radiology-study observation

18782-3

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

Radiology-impression

19005-8

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

Radiology study-recommendation (narrative)

18783-1

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

Computed Tomographic Angiography (CTA) Heart, 04-70540-03

OTHER:

Other names used to report computed tomography (CT Heart):

Cardiac Computed Tomography (CT)

Cardiac CT

Abbreviations

ACCF = American College of Cardiology Foundation

ACS = acute coronary syndrome

AHA = American Heart Association

ASE = American Society of Echocardiography

ASNC = American Society of Nuclear Cardiology

CABG = coronary artery bypass grafting surgery

CAD = coronary artery disease

CCS = coronary calcium scoring

CCTA = coronary computed tomographic angiography

CHD = coronary heart disease

CMR = cardiac magnetic resonance imaging

CT = computed tomography

CTA = computed tomographic angiography

ECG = electrocardiogram

HF = heart failure

MET = estimated metabolic equivalent of exercise

MI = myocardial infarction

MPI= myocardial perfusion imaging or nuclear cardiac imaging

MRI= magnetic resonance imaging

NASCI = North American Society for Cardiac Imaging

PCI = percutaneous coronary intervention

PET= positron emission tomography

RV = right ventricle

SCAI = Society for Cardiovascular Angiography and Interventions

SCCT = Society for Cardiovascular Computed Tomography

SCMR = Society for Cardiovascular Magnetic Resonance

SE = stress echocardiography

TGA = transposition of the great arteries

TR = tricuspid regurgitation

TTE= transthoracic echocardiography

REFERENCES:

  1. Datta J, White CS, Gikeson RC et al. Anomalous Coronary Arteries in Adults: Depiction at Multi-Detector Row CT Angiography. Radiology 2005; 235(3): 812 – 818.
  2. Douglas PS, Garcia MJ, Haines DE et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology 2011; 57 (9): 1126-1166.
  3. Fihn SD, Blankenship JC, Alexander KP et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Journal of the American College of Cardiology 2014; 64 (18): 1929-1949.
  4. 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.
  5. National Imaging Associates, Inc. CT Heart Clinical Guidelines, 2018.
  6. Taylor AJ, Cerqueira M, Hodgson JM et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology 2010; 56 (22): 1864-1894.
  7. Wolk MJ, Bailey SR, Doherty JU et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. Journal of the American College of Cardiology 2013; 63 (4): 380-406.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

05/15/18

New Medical Coverage Guideline.

Date Printed: May 27, 2018: 07:42 PM