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Date Printed: September 1, 2015: 10:02 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2015, 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 2015 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.

04-70450-02

Original Effective Date: 03/15/04

Reviewed: 01/22/15

Revised: 02/15/15

Subject: Computed Tomography to Detect Coronary Artery Calcification

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 Updates    

DESCRIPTION:

Electron-beam computed tomography [EBCT] (also known as cine, ultrafast computed tomography) uses an electron gun rather than a standard x-ray tube to generate x-rays. The EBCT uses specialized equipment to acquire serial transaxial images of the coronary arteries in 100 milliseconds. Spiral computed tomography scanning (also known as helical CT scanning creates images at greater speeds by rotating a standard x-ray tube around the patient such that data are gathered in a continuous spiral or helix rather than individual slices. For example, the rapid image acquisition time virtually eliminates motion artifact related to cardiac contraction, permitting visualization of the calcium in the epicardial coronary arteries. EBCT software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting coronary artery calcification, both as a technique to diagnostic technique in symptomatic patients to determine the necessity of coronary angiography, or, in asymptomatic patients, as a screening technique for coronary artery disease.

POSITION STATEMENT:

Electron beam computed tomography (EBCT) and spiral computed tomography to detect coronary artery calcification (e.g., evaluation of coronary artery disease, diagnosing coronary artery disease, screening for coronary artery disease) is considered experimental or investigational, as there is insufficient evidence in the published peer-reviewed scientific literature to support conclusions regarding the effects of EBCT and spiral CT on health outcomes. Available published clinical studies fail to establish a clear screening role for EBCT in asymptomatic patients, nor have any studies shown that clinical outcomes can be favorably altered by the use of screening EBCT.

The U.S. Preventive Services Task Force recommends against routine screening with EBCT scanning for coronary calcium for either the presence of severe coronary artery stenosis or the prediction of coronary heart disease events in adults at low risk for coronary heart disease events.

BILLING/CODING INFORMATION:

CPT Coding:

75571

Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (investigational)

HCPCS Coding:

S8092

Electron beam computed tomography (also known as ultrafast CT, cine CT) (investigational)

ICD-9 Diagnoses Codes That Support Medical Necessity:

All diagnoses for electron-beam CT scanning are considered experimental or investigational.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

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 BCBSF 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:

The following Local Coverage Determination (LCD) was reviewed on the last guideline revised date: Computed Tomographic Angiography of the Chest, Heart and Coronary Artery, (L29117) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Computed Tomographic Angiography (CTA), 04-70450-03

OTHER:

Other names used to report electron-beam CT scanning of the heart:

Note: 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.

Cine Computed X-ray Tomography
Computed X-ray Tomography
Coronary Calcium Scan
Electron Beam Computed Tomography (EBCT)
Electron Beam CT
Electron Beam Tomography (EBT)
HeartScan
High-Speed Rapid Acquisition X-ray Computed Tomography
Spiral Computed Tomography (Spiral CT) (Helical Computed Tomography Scanning)
Ultrafast Computed Tomography (Ultrafast CT)

REFERENCES:

  1. American College of Cardiology/American Heart Association Expert Consensus Document on Electron-Beam Computed Tomography for the Diagnosis and Prognosis of Coronary Artery Disease, (June 2000).
  2. Blue Cross Blue Shield Association Medical Policy Computed Tomography to Detect Coronary Artery Calcification 6.01.03, 05/14.
  3. Blue Cross Blue Shield Association Technology Assessment Diagnosis and Screening for Coronary Artery Disease with Electron Beam Computed Tomography, Vol. 13, No. 27, 03/99.
  4. Budoff MJ, Shaw LJ, Liu ST et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. Journal of the American College of Cardiology 2007; 49: 1860-1870.
  5. Clouse ME. How useful is computed tomography for screening for coronary artery disease? Circulation 2006; 113: 124-146.
  6. Detrano RC, Wong ND, Doherty TM et al. Coronary Calcium Does Not Accurately Predict Near-Term Future Coronary Events in High-Risk Adults. Circulation 1999; 99:2633-2638.
  7. ECRI Institute Emerging Technology (TARGET) Evidence Report Electron-Beam Computed Tomography (EBCT) for Coronary Artery Disease (CAD) Screening #529, 08/04.
  8. ECRI Institute Windows on Medical Technology™ Technology Assessment. Computed Tomography for Predicting Coronary Artery Disease Risk #107, 04/04.
  9. Elkeles RS, Godsland IF, Feher MD et al. Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study. European Heart Journal 2008; 29(18): 2244-2251.
  10. First Coast Service Options, Inc. LCD for Computed tomographic angiography of the chest, heart and coronary arteries (L29117), 10/01/11.
  11. Greenland et al. ACCF/AHA 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients with Chest Pain. Circulation 2007; 115; 402-426.
  12. Greenland P, LaBree L, Azen S et al. Coronary Artery Calcium Combined with Framingham Score for Risk Prediction in Asymptomatic Individuals. The Journal of the American Medical Association (JAMA) 2004; 291(2): 210-215.
  13. Hayes Medical Technology Directory Electron Beam Computed Tomography for Coronary Artery Disease, 06/03. Updated Search 04/16/06.
  14. Lakoski SG, Greenland P, Wong ND et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Archives of Internal Medicine 2007; 167(22): 2437-24442.
  15. Mozaffarian D. Electron-Beam Computed Tomography for Coronary Calcium A Useful Test to Screen for Coronary Heart Disease? The Journal of the American Medical Association (JAMA) 2005; 294(22): 2897-2901.
  16. National Imaging Associates, Inc. Electron-Beam Tomography (EBCT) Clinical Guideline, 09/14.
  17. O’Malley PG, Feuerstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavorial change, and cardiovascular risk profile: a randomized controlled trial. JAMA 2003; 289(17): 2215-2223.
  18. O'Rouke RA, Brundage BH, Froelicher VF et al. American College of Cardiology/American Heart Association Expert Consensus Document on Electron-Beam Computed Tomography for the Diagnosis and Prognosis of Coronary Artery Disease. Circulation 2000; 102(1): 126-140.
  19. Poon M, Rubin GD, Achenbach S et al. Consensus update on the appropriate usage of cardiac computed tomographic angiography. The Journal of Invasive Cardiology 2007; 19(11): 484-490.
  20. U.S. Food and Drug Administration (FDA) Center For Devices and Radiological Health 510(k) Premarket Notification Database-Ultrafast CT Scanner, 01/08/08.
  21. U.S. Preventive Services Task Services (USPSTF) Using nontraditional risk factors in coronary heart disease risk assessment, 10/09.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/22/15.

GUIDELINE UPDATE INFORMATION:

03/15/04

New Medical Coverage Guideline.

03/15/05

Scheduled review, no change in coverage statement, and updated references.

01/15/06

HCPCS update, added 0144T. Updated references.

03/15/06

Updated references.

03/15/07

Scheduled review, no change in coverage statement, and updated references.

06/15/07

Reformatted guideline.

07/01/07

Updated Program Exceptions.

01/21/08

Updated Program Exceptions.

03/15/08

Scheduled review; no change in position statement. Revised 0144T code descriptor. Added coronary calcium scan to other section, and updated references.

03/15/09

Scheduled review. No change in position statement (experimental or investigational), and updated references.

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.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Annual HCPCS coding update: deleted 0144T. Added 75571. Revised BCBSF Radiology Management program exception section.

03/15/10

Scheduled review. No change in position statement (experimental or investigational), and updated references.

03/15/12

Scheduled review. No change in position statement. Updated references.

12/15/12

Added Medicare program exception. Added Computed Tomographic Angiography (CTA), 04-70450-03 to related guidelines section.

05/11/14

Revision: Program Exceptions section updated.

02/15/15

Annual review. No change in position statement.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, 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 2013 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.

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Date Printed: September 1, 2015: 10:02 AM