Cardiac Computed Tomography Angiography

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Name of Policy:
Cardiac Computed Tomography (CCT), Cardiac Computed
Tomography Angiography (CCTA)
Policy #: 230
Category: Radiology
Latest Review Date: December 2014
Policy Grade: C
Background/Definitions:
As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health
plans only in cases of medical necessity and only if services or supplies are not investigational,
provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be
considered for coverage:
1. The technology must have final approval from the appropriate government regulatory
bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology
on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies,
devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment,
would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an
illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and
considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider;
and
4. Not more costly than an alternative service or sequence of services at least as likely to
produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of
that patient’s illness, injury or disease.
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Description of Procedure or Service:
Cardiac Computed Tomography (CCT) or Cardiac Computed Tomography Angiography
(CCTA) 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 or heart structure. To apply CCT/CCTA 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.
Volumetric imaging permits multiplanar reconstruction (MPR) of cross-sectional images to
display the coronary arteries. Curved MPR and thin-slab maximum intensity projections (MIPs)
provide an overview of the coronary arteries, and volume-rendering techniques (VRT) provide a
3D anatomical display of the exterior of the heart. Two different CT technologies can achieve
high-speed CT imaging. Electron beam CT (EBCT, also known as ultrafast CT) uses an electron
gun rather than a standard x-ray tube to generate x-rays, thus permitting very rapid scanning, on
the order of 50 to100 milliseconds per image. Helical CT scanning (also referred to as spiral CT
scanning) also creates images at greater speed than conventional CT by continuously rotating a
standard x-ray tube around the patient so that data are gathered in a continuous spiral or helix
rather than individual slices. Helical CT is able to achieve scan times of 500 milliseconds or less
per image and use of partial ring scanning or post-processing algorithms may reduce the
effective scan time even further.
Multidetector row helical CT (MDCT) or multislice CT (MSCT) scanning is a technological
evolution of helical CT, which uses CT machines equipped with an array of multiple x-ray
detectors that can simultaneously image multiple sections of the patient during a rapid
volumetric image acquisition. MDCT machines currently in use have 64 or more detectors.
A variety of noninvasive tests are used in the diagnosis of coronary artery disease (CAD). They
can be broadly classified as those that detect functional or hemodynamic consequences of
obstruction and ischemia (exercise treadmill testing, myocardial perfusion imaging [MPI], and
stress echocardiography with or without contrast), and others that identify the anatomic
obstruction itself (coronary CTA and coronary magnetic resonance imaging [MRI]). Functional
testing involves inducing ischemia by exercise or pharmacologic stress and detecting its
consequences. However, not all patients are candidates. For example, obesity or obstructive
lung disease can make obtaining echocardiographic images of sufficient quality difficult.
Conversely, the presence of coronary calcifications can impede detecting coronary anatomy with
coronary CTA. Accordingly, some tests will be unsuitable for particular patients.
Evaluation of obstructive CAD involves quantifying arterial stenoses to determine whether
hemodynamically significant stenosis is present. Symptomatic lesions with greater than 50%–
75% diameter stenosis are generally considered significant and often result in revascularization
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procedures when viable myocardium is present. It has been suggested that CCT/CCTA may be
helpful to rule out the presence of CAD and to avoid invasive coronary angiography in patients
with a very low clinical likelihood of significant CAD. Also of note is the increasing interest in
exploring the role of nonsignificant plaques (i.e., those associated with less than 50% stenosis)
because their presence is associated with increased cardiac event rates. Cross-sectional
angiographic imaging may visualize the presence and composition of these plaques and quantify
the plaque burden better than conventional angiography, which only visualizes the vascular
lumen. Plaque presence has been shown to have prognostic importance.
The information sought from angiography after coronary artery bypass graft surgery may depend
on the length of time since surgery. Bypass graft occlusion may occur during the early
postoperative period; whereas, over the long term, recurrence of obstructive CAD may occur in
the bypass graft, which requires a similar evaluation as CAD in native vessels.
Congenital coronary arterial anomalies (i.e., abnormal origination or course of a coronary artery)
that lead to clinically significant problems are relatively rare lesions. Symptomatic
manifestations may include ischemia or syncope. Clinical presentation of anomalous coronary
arteries is hard to distinguish from other more common causes of cardiac disease; however,
anomalous coronary artery is an important diagnosis to exclude, particularly in young patients
who present with unexplained symptoms (e.g., syncope). There is no specific clinical
presentation to suggest a coronary artery aneurysm.
CCT/CCTA has several important limitations. The presence of dense arterial calcification or an
intracoronary stent can produce significant beam-hardening artifacts and 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.
Radiation delivered with current generation scanners utilizing reduction techniques (prospective
gating and spiral acquisition) has declined substantially—typically to under 10mSv. For
example, an international registry developed to monitor coronary CTA radiation recently
reported a median 2.4mSv (interquartile range, 1.3-5.5) exposure. In comparison, radiation
exposure accompanying rest-stress perfusion imaging ranges varies according to isotope used—
approximately 5mSv for rubidium-82 (positron emission tomography [PET]), 14mSv for F-18
FDG (PET), 9mSv for sestamibi (single-photon emission computed tomography [SPECT]), and
41mSv for thallium; during diagnostic invasive coronary angiography, approximately 7mSv will
be delivered. EBCT using electrocardiogram (ECG) triggering delivers the lowest dose (0.7-1.1
mSv with 3-mm sections). Any cancer risk due to radiation exposure from a single cardiac
imaging test depends on age (higher with younger age at exposure) and sex (greater for women).
Empirical data suggest that every 10mSv of exposure is associated with a 3% increase in cancer
incidence over five years.
The use of electron beam CT to detect coronary artery calcification is addressed in a separate
policy: #104- Computed Tomography to Detect Coronary Artery Calcification.
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Policy:
Effective for dates of service on or after December 28, 2011:
Contrast-enhanced computed tomographic angiography for the evaluation of patients
without known coronary artery disease and acute chest pain in the emergency
room/emergency department setting meets Blue Cross and Blue Shield of Alabama’s medical
criteria for coverage. See page 4, Evaluation #III for specific criteria.
Cardiac Computed Tomography (CCT), Cardiac Computed Tomography Angiography
(CCTA) using a 64-slice or greater CT scanner meets Blue Cross and Blue Shield of Alabama’s
medical criteria for coverage for any of the following conditions:
I.
Detection of CAD: Symptomatic
a. Evaluation of chest pain syndrome
i. Intermediate pre-test probability* of CAD and ECG uninterpretable or
unable to exercise
b. Evaluation of intra-cardiac structures
i. Evaluation of suspected coronary anomalies
c. Acute chest pain
i. Intermediate pre-test probability* of CAD and no ECG changes and serial
enzymes negative
II.
Detection of CAD with prior test results
a. Evaluation of chest pain syndrome
i. Un-interpretable or equivocal stress test (exercise, perfusion, or stress
echo)
III.
Evaluation
a. Evaluation of acute chest pain in the Emergency Room/Emergency Department of
the hospital for patients with low to moderate pre-test probability of CAD that
meet all of the following criteria:
i. No known coronary artery disease;
ii. No elevated serum biomarkers including creatine kinase-myocardial band,
myoglobin and/or troponin I;
iii. No ischemic EKG changes such as ST-segment elevation or depression
≥1mm in 2 or more contiguous leads, and or T-wave inversion ≥2ml;
iv. No previously known cardiomyopathy with an estimated ejection fraction
≤ 45%.
IV.
Structure and Function
a. Morphology
i. Assessment of complex congenital heart disease including anomalies of
coronary circulation, great vessels, and cardiac chambers and valves
ii. Evaluation of coronary arteries in patients with new onset heart failure to
assess etiology
b. Evaluation of intra- and extra-cardiac structures
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i. Evaluation of cardiac mass (suspected tumor or thrombus) and patients
with technically limited images from echocardiogram, MRI or TEE
ii. Evaluation of pericardial conditions (pericardial mass, constrictive
pericarditis, or complications of cardiac surgery) and patients with
technically limited images from echocardiogram, MRI or TEE
iii. Evaluation of pulmonary vein anatomy prior to invasive radiofrequency
ablation for atrial fibrillation (e.g., pulmonary vein isolation)
iv. Non-invasive coronary vein mapping prior to placement of biventricular
pacemaker or, effective for dates of service on or after November 24,
2008, placement of automatic implantable cardioverter defibrillator
(AICD)
v. Non-invasive coronary arterial mapping, including internal mammary
artery prior to repeat cardiac surgical revascularization
c. Evaluation of aortic and pulmonary disease
i. Evaluation of suspected aortic dissection or thoracic aortic aneurysm
ii. Evaluation of suspected pulmonary embolism
*Refer to Key Points for definition of pretest probability.
Contrast-enhanced computed tomographic angiography (CTA) of the coronary arteries does
not meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage if performed
for indications not listed above or when imaged with less than a 64-slice CT scanner.
Computed tomography, heart, without contrast material including image post-processing and
quantitative evaluation of coronary calcium meets Blue Cross and Blue Shield of Alabama’s
medical criteria for coverage when a CCT or CCTA meets the coverage criteria noted above, but
when a review of the initial non-contrast CT images is reviewed it is determined that based on
the calcium volume the patient is not a candidate for the arterial phase component of the study.
(In this case only code 75571 should be reported.)
The evaluation of calcium volume as a stand alone test does not meet Blue Cross and Blue
Shield of Alabama’s medical criteria for coverage and is considered investigational.
The following are contraindications to CCT/CCTA:
•
•
•
•
•
•
Irregular rhythm (e.g., atrial fibrillation/flutter, frequent irregular premature ventricular
contractions or premature atrial contractions, and high grade heart block).
Very obese patients, body mass index > 40 kg/m2.
Renal insufficiency, creatinine > 1.8 mg/dl.
Heart rate > 70 beats/minute refractory to heart-rate lowering agents (e.g., a combination
of beta-blocker and calcium-channel blocker)
Metallic interference (e.g., surgical clips, pacemaker, and/or defibrillator wires, or tissue
expander
Calcium score > 1,000
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Proprietary Information of Blue Cross and Blue Shield of Alabama
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Blue Cross and Blue Shield of Alabama does not approve or deny procedures, services, testing,
or equipment for our members. Our decisions concern coverage only. The decision of whether
or not to have a certain test, treatment or procedure is one made between the physician and
his/her patient. Blue Cross and Blue Shield of Alabama administers benefits based on the
member’s contract and corporate medical policies. Physicians should always exercise their best
medical judgment in providing the care they feel is most appropriate for their patients. Needed
care should not be delayed or refused because of a coverage determination.
Key Points:
This policy was originally based on a literature search conducted on MEDLINE via PubMed
through February 2004 and updated with subsequent literature review and/or repeat TEC
Assessments. The most recent literature review covers the period through October 16, 2014.
The objective of the 2005 TEC Assessment was to evaluate the clinical effectiveness of contrastenhanced cardiac computed tomography angiography (CTA) using either electron beam
computed tomography (EBCT) or multidetector-row computed tomography (MDCT) as a
noninvasive alternative to invasive coronary angiography (CA), particularly in patients with a
low probability of significant coronary artery stenosis. Evaluation of the coronary artery anatomy
and morphology is the most frequent use of cardiac CTA and was the primary focus of the TEC
Assessment. The TEC Assessment concluded that the use of contrast-enhanced cardiac CT
angiography for screening or diagnostic evaluation of the coronary arteries did not meet TEC
criteria.
The 2006 TEC Assessment was undertaken to determine the usefulness of cardiac CTA as a
substitute for ICA for two indications: in the diagnosis of coronary artery stenosis and in the
evaluation of acute chest pain in the emergency department (ED). Seven studies in the
ambulatory setting and utilizing 40- to 64-slice scanners were identified. Two studies performed
in the ED used 4- or 16-slice scanners. Evidence was judged insufficient to form conclusions.
Available studies at the time were inadequate to determine the effect of cardiac CTA on health
outcomes for the diagnosis of coronary artery stenosis in patients referred for angiography or for
evaluation of acute chest pain in the ED.
Stable Patients With Angina and Suspected Coronary Artery Disease
Before the introduction of coronary CTA, the initial noninvasive test in a diagnostic treatment
strategy was always a functional test. The choice of functional test is based on clinical factors
such as sex of the patient, ECG abnormalities, and chest pain characteristics. Patients with
suspicious findings are often referred to invasive angiography. When disease is detected,
treatment alternatives include medical therapy or revascularization (percutaneous coronary
intervention or coronary artery bypass graft surgery). Which approach to adopt is based on the
extent of anatomic disease, symptom severity, and evidence of ischemia from functional testing,
noninvasive testing, or more recently, FFR obtained during invasive angiography. A difficulty in
evaluating a noninvasive diagnostic test for CAD is that it is part of testing and treatment
strategy. The most informative and convincing evidence would accordingly compare outcomes
after anatomic-first (coronary CTA) and functional-first (e.g., perfusion imaging, stress
echocardiography) strategies. Lacking direct comparative evidence, steps or links in the testingPage 6 of 28
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treatment pathway must be examined including diagnostic accuracy, need for invasive
angiography after a noninvasive test, prognosis after a negative test, and likely outcomes of
treatment based on information provided by the test.
Relevant studies reviewed here include multicenter studies comparing diagnostic performance of
coronary CTA with angiography for evaluation of native arteries, studies of incidental findings,
radiation exposure, prognosis, outcomes, and studies of downstream or subsequent testing – all
important considerations when comparing coronary CTA in the diagnostic-treatment pathway
with alternatives.
Diagnostic Accuracy
In 2014, Nielson et al published a systematic review and meta-analysis to compare diagnostic
accuracy and outcomes after coronary CTA (≥16 slice) or functional testing (exercise-ECG and
single-photon emission computed tomography [SPECT]) in patients suspected of stable CAD.
Literature was searched through January 2013; eleven studies comparing diagnostic accuracy
(for ≥50% stenosis on ICA; total N=1575) and seven studies comparing outcomes (total
N=216,603) were included. Diagnostic performance of coronary CTA for detecting significant
CAD was statistically better compared with both exercise ECG and SPECT: For CTA versus
exercise ECG, respectively, per-patient sensitivity was 98% (95% CI, 93 to 99) versus 67%
(95% CI, 54 to 78) (p<0.001), and specificity was 82% (95% CI, 63 to 93) versus 46% (95% CI,
30 to 64) (p<0.001). For CTA versus SPECT, respectively, sensitivity was 99% (95% CI, 96 to
100) versus 73% (95% CI, 59 to 83) (p=0.001), and specificity was 71% (95% CI, 60 to 80)
versus 48% (95% CI, 31 to 64) (p=0.14). In random effects (for high [>20%] statistical
heterogeneity) or fixed (for homogeneity) meta-analyses, coronary CTA was associated with
increased downstream test utilization (pooled odds ratio [OR] for eight studies: 1.38 [95% CI,
1.33 to 1.43]; p<0.001; I2=99%), increased ICA (pooled OR for eight studies: 2.25 [95% CI,
2.17 to 2.34]; p<0.001; I2=98%), increased coronary revascularization (pooled OR for seven
studies: 2.63 [95% CI, 2.50 to 2.77]; p<0.001; I2=89%), and decreased non-fatal MI (pooled OR
for six studies: 0.53 [95% CI, 0.39 to 0.72]; p<0.001; I2=0%) compared with exerciseECG/SPECT.
Four multicenter studies evaluated the diagnostic accuracy of coronary CTA employing ICA as
referent standard. All patients enrolled in the 4 studies were scheduled for ICA; the population of
interest here is patients at intermediate risk only, a minority of whom would proceed to ICA.
ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals
Undergoing Invasive Coronary Angiography) compared coronary CTA with ICA in 230 of 245
individuals experiencing typical or atypical chest pain referred for nonemergent ICA. Three
readers blinded to ICA results interpreted coronary CTA scans. Of the 143 normal coronary CTA
scans, ICA was normal in 142 (NPV, 99%); the false-positive rate was 17%. Radiation dose,
prevalence of incidental noncardiac findings, and follow-up were not reported. Using a 50%
stenosis cutoff, disease prevalence was 25%, with 13% having 70% or greater stenosis.
Estimated pretest disease probability was not reported.
CORE 64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography
Angiography) evaluated 405 individuals referred for ICA to evaluate suspected CAD at nine
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centers. There were 89 patients (22%) excluded from analyses due to Agatston calcium score
greater than 600; results from 291 of 316 remaining individuals were analyzed. Coronary CTA
was the initial diagnostic test, and investigators and physicians were subsequently blinded to
coronary CTA results. Sensitivity was 85%; NPV, 83%; and false-positive rate, 10%. Coronary
CTA radiation dose was 13.8±1.2 mSv for men and 15.2±2.4 mSv for women. Noncardiac
findings were reported to the treating physician but were not described in the report. Disease
prevalence was 56%, using a 50% stenosis cutoff. Pretest disease probability was not reported. In
a subsequent analysis of this study that included all eligible patients regardless of Agatston
calcium score, diagnostic performance of coronary CTA was similar between groups defined by
suspected acute coronary syndrome (ACS) (typical angina at rest for at least 20 minutes, or
relieved with nitrates at <20 minutes with associated ischemic ECG changes; angina-equivalent
symptoms with associated transient ST segment changes on ECG; or angina-equivalent
symptoms associated with abnormal cardiac enzymes; n=94) or non-ACS (no ACS features
present; n=277).27 Sensitivity, specificity, PPV, and NPV were 90% (95% CI, 80 to 96), 88%
(95% CI, 70 to 98), 95% (95% CI, 87 to 99), and 77% (95% CI, 58 to 90), respectively, in the
ACS group, and 87% (95% CI, 81 to 92), 86% (95% CI, 79 to 92), 91% (95% CI, 85 to 95), and
82% (95% CI, 74 to 89), respectively, in the non-ACS group (chi-square p values statistically
nonsignificant for all comparisons).
Meijboom et al in 2008 evaluated 433 individuals, aged 50 to 70 years, seen at three university
hospitals referred for ICA to evaluate suspected stable or unstable angina; 371 consented to
participate and 360 completed the study. Tests were interpreted in blinded fashion. Sensitivity
was 99%; NPV, 97%; and false-positive rate, 36%. Estimated radiation exposure based on
instrument parameters was 15 to 18mSv. Frequency of noncardiac findings was not reported.
Disease prevalence was 68%, using a 50% stenosis cutoff; pretest probability was not reported.
Chow et al in 2011 obtained consent from 181 patients and examined 169 of 250 eligible patients
referred to ICA for evaluation of CAD (n=117) or structural heart disease (n=52). Four centers
evaluated differing numbers of patients: 102 (60.3%), 40 (23.7%), 16 (9.5%), and 11 (6.5%),
respectively. Overall sensitivity for obstructive CAD was 81%; NPV, 85%; and false-positive
rate, 7%. Performance characteristics differed substantially and significantly by site. The center
enrolling most of the patients reported sensitivity, specificity, NPV and PPV of 93%, 93%, 91%,
and 95%, respectively; the other three centers reported values of 67%, 93%, 92%, and 71%,
respectively. Estimated mean (SD) radiation exposure was 11.0 (6.8) mSv. Disease prevalence
was 53%, using a 50% stenosis cutoff and mean estimated pretest probability of CAD 47%.
There was variability in coronary CTA diagnostic accuracy reported from these multicenter
studies spanning different disease prevalence populations. The lower sensitivity reported by
Chow et al is notable, as well as the considerable between-center variability. In contrast to the
others, the study used visual ICA assessment as a referent standard. Although arguably, visual
assessment is most often used in practice, it is prone to imprecision. Although Chow et al
reported high interobserver agreement for ICA (
=0.88),
experienced
Zir et al found four
observers agreed 65% of the time whether a stenosis exceeded 50% in 20 angiograms. Finally,
the small number of patients enrolled from three centers relative to overall annual coronary CTA
volume (center 1: 102/1325; 2: 40/1539; 3: 11/1773; 4: 16/268) might reflect sampling
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variability (screening procedures or whether consecutive patients were approached was not
reported).
Patient populations included in each study varied, as did disease prevalence. Estimates of pretest
disease probability were not reported except by Chow et al, but given that all patients were
referred to ICA, pretest probability was presumably at least in the upper intermediate range. With
these caveats, the studies supported the conclusion that coronary CTA is sensitive for detecting
stenoses in samples with varying disease prevalences. Sensitivities are at least as good those
cited for other noninvasive tests; false positives are not uncommon, but the rate is similar to
other noninvasive tests. However, as suggested by Chow et al, sensitivity and specificity
achieved in the real world are likely lower than those reported under more carefully controlled
conditions. These results are, however, subject to verification bias, because all patients were
referred for ICA. Performance characteristics reported from these studies, as well as for
noninvasive tests among patients selectively referred to ICA, might differ in practice when the
test is used in patients not referred. In comparison, a recent meta-analysis including smaller
single-center studies (42 total) estimated pooled sensitivity and specificity of 98% and 85%,
respectively. Finally, radiation exposure reported in these studies was consistent with others
using retrospective gating. Current prospective gating techniques result in lower radiation doses.
Incidental Findings
Nine studies using 64+-slice scanners were identified. Incidental findings were frequent (26.6%68.7%) with pulmonary nodules typically the most common and cancers rare (5/1000 or less). In
2010, Aglan et al compared the prevalence of incidental findings when the field of view was
narrowly confined to the cardiac structures with that when the entire thorax was imaged. As
expected, incidental findings were less frequent in the restricted field (clinically significant
findings in 14% vs 24% when the entire field was imaged).
Prognosis
Hulten et al in 2011 performed a meta-analysis of 18 studies (total N=9592) with three or more
months of follow-up (median, 20 months) enrolling patients with suspected CAD (mean age, 59
years; 58% male). Annualized death or MI rates after a normal coronary CTA (no identified
stenosis >50%) was 0.15%. The pooled rate included two studies of EBCT and four that used 16slice scanners; most events in the normal group occurred in one of the EBCT studies. Bamberg et
al (2011) pooled results from nine studies (total N=3670) enrolling 100 or more patients with
suspected CAD (mean age, 59.1±2.6 years; 63% male) with one or more years of follow-up. The
pooled annualized event rate (all-cause and cardiac death, MI, unstable angina, revascularization)
was 1.1% after a coronary CTA without evidence of significant stenosis; in the 38% of patients
without evidence of any atherosclerotic plaque, the annual event rate was 0.4%. In comparison,
Metz et al (2007)45 performed a meta-analysis of event rates after a negative MPI and stress
echocardiography. The pooled annual cardiac death and MI rates after negative MPI (17 studies;
total N=8008) and stress echocardiography (four studies; total N=3021) were 0.45% and 0.51%,
respectively.
Subsequent or Downstream Testing
Whether tests are used to replace, or add to, others currently in use is relevant. Few studies have
addressed this issue. In an analysis of 2006 data from patients without CAD, as recorded in
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claims data, Min et al found that after MPI, 11.6% of 6588 patients underwent subsequent MPI,
coronary CTA, or invasive angiography; after coronary CTA, 14.6% of 1647 patients underwent
one of those tests. A study of Medicare claims from 2005 to 2008 showed similar results.
Compared with MPI, patients undergoing CTA had a higher likelihood of subsequent cardiac
catheterization (22.9% vs 12.1%), and higher rates of percutaneous coronary procedures and
bypass surgery. Aggregate healthcare spending was higher in patients who had CTA. The study
was limited by a lack of follow-up for cardiac events. Cheezum et al in 2011 retrospectively
identified 241 symptomatic patients without known CAD undergoing coronary CTA and
matched them by age and sex to 252 symptomatic patients undergoing MPI. After coronary
CTA, downstream testing (11.5% vs 17.0%) and ICA were less frequent (3.3% vs 8.1%)
compared with MPI. Finally, coronary CTA and ICA in Ontario are centralized to a single
academic center in Ottawa, which allowed investigators to examine coronary CTA accuracy
concurrent with the impact on ICA referrals. Consecutive patients (N=3538) were evaluated by
ICA during 14 months before and in the 12 months after (n=3479) coronary CTA introduction.
The rate of normal ICA decreased from 31.5% before to 26.8% after coronary CTA introduction
(p=0.003). During the same period at three other centers without coronary CTA programs,
normal ICA rates increased from 30.0% to 31.0%. The 2012 Study of Myocardial Perfusion and
Coronary Anatomy Imaging Roles in Coronary Artery Disease (SPARC), is a prospective
multicenter registry study of imaging modalities. In 1703 patients with no history of CAD,
angiography was more frequent within 90 days after coronary CTA (13.2%) compared with
SPECT (4.3%) or positron emission tomography (PET) (11.1%). Although study results vary and
all are observational with the attendant potential for selection bias (in effect, confounding by test
selection), angiography rates appear higher after coronary CTA.
Outcome Studies
In 2825 patients evaluated for stable angina and suspected CAD in Japan, Yamauchi et al
examined outcomes after initial coronary CTA (n=625), MPI (n=1205), or angiography (n=950).
Average follow-up was 1.4 years. In a Cox proportional hazards model adjusted for potential
confounders, the relative hazard of major cardiac events after MPI or coronary CTA were lower
than after angiography; annual rates of 2.6%, 2.1%, and 7.0%, respectively. Revascularization
rates were higher after coronary CTA than MPI (OR=1.6; 95% CI, 1.2 to 2.2). However, results
are limited by the observational nature of the data and difficulty controlling for selection bias in
conventional analysis.
Radiation Exposure
Exposure to ionizing radiation increases lifetime cancer risk. Three studies have estimated excess
cancer risks due to radiation exposure from coronary CTA. Assuming a 16-mSv dose, Berrington
de Gonzalez et al estimated that the 2.6 million coronary CTAs performed in 2007 would result
in 2,700 cancers or approximately one per 1,000. Smith-Bindman et al estimated cancer would
develop in one of 270 women and one of 600 men age 40 undergoing coronary CTA with a 22mSv dose. Einstein et al employed a standardized phantom to estimate organ dose from 64-slice
coronary CTA. With modulation and exposures of 15mSv in men and 19mSv in women, the
calculated lifetime cancer risk at age 40 was seven per 1,000 men (1 in 143) and 23 per 1,000
women (1 in 43). However, estimated radiation exposure used in these studies is considerably
higher than received with current scanners—now typically under 10mSv and often less than
5mSv with contemporary machines and radiation reduction techniques. For example, in the 47Page 10 of 28
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center PROTECTION I study enrolling 685 patients; the mean radiation dose was 3.6mSv, using
a sequential scanning technique.
Although indirectly related to coronary CTA, Eisenberg et al analyzed administrative data from
82,861 patients undergoing imaging or procedure accompanied by radiation between April 1996
and March 2006 with 12,020 incident cancers identified. Based on estimated radiation exposures
accompanying various cardiac imaging and procedures, over five years, there was an increased
relative hazard for cancer of 1.003 per mSv (95% confidence interval [CI]: 1.002-1.004).
A number of multicenter studies have evaluated the diagnostic accuracy of CTA for diagnosing
coronary ischemia in an outpatient population. In general, these studies report high sensitivity
and specificity, but there is some variability in these parameters across studies. Use of CTA in
this situation does not have the same advantage of improving the efficiency of diagnosis as it
does in the emergency setting. There is evidence that angiography rates are higher after coronary
CTA. Evidence defining comparative outcomes outside the ED setting is limited. Lacking direct
comparative outcome evidence, the risk/benefit ratio in patients with stable angina and suspected
CAD depends on the diagnostic accuracy, downstream testing, impact of incidental findings, and
the amount of radiation exposure. Given the uncertainty in these factors, it is not possible to
conclude that the use of CTA in this setting leads to improved outcomes compared with
alternative strategies. Therefore CTA is considered investigational when used in the outpatient
setting to evaluate patients with suspected cardiac ischemia.
Patients With Acute Chest Pain Presenting to the Emergency Setting
A 2011 TEC Assessment examined evidence surrounding the evaluation of patients with acute
chest pain and without known coronary artery disease (CAD). Randomized controlled trials
(RCTs) and prospective observational studies reporting prognosis were identified by searching
the MEDLINE database and relevant bibliographies of key studies.
Several RCTs of CTA conducted in emergency settings were identified. A 2007 RCT by
Goldstein et al evaluated 197 randomized patients from a single center without evidence of acute
coronary syndromes to coronary CTA with 64-slice scanners (n=99) or usual care (n=98). Over a
six-month follow-up, no cardiac events occurred in either arm. Invasive coronary angiography
rates were somewhat higher in the coronary CTA arm (12.1% vs 7.1%). Diagnosis was achieved
more quickly after coronary CTA. A 2009 RCT evaluated a similar sample of 699 randomized
patients from 16 centers – 361 undergoing coronary CTA with 64- to 320-slice scanners and 338
undergoing myocardial perfusion imaging (MPI). Over a six-month follow-up, there were no
deaths in either arm, two cardiac events in the coronary CTA arm and one in the perfusion
imaging arm. Invasive coronary angiography rates were similar in both arms (7.2% after
coronary CTA; 6.5% after perfusion imaging). A second noninvasive test was obtained more
often after coronary CTA (10.2% vs 2.1%), but cumulative radiation exposure in the coronary
CTA arm (using retrospective gating) was significantly lower – mean 11.5 versus 12.8mSv.
Time to diagnosis was shorter (mean, 3.3 hours) and estimated ED costs lower with coronary
CTA.
A 2012 RCT by Litt et al also evaluated the safety of coronary CT in the evaluation of patients in
the ED. Although the study was a randomized comparison with traditional care, principal
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outcome was safety after negative CTA examinations. No patients who had negative CTA
examinations (n=460) died or had a myocardial infarction (MI) within 30 days. Compared with
traditional care, patients in the CTA group had higher rates of discharge from the ED (49.6% vs
22.7%), a shorter length of stay (median, 18.0 hours vs 24.8 hours), and a higher rate of detection
of coronary disease (9.0% vs 3.5%). Three studies reported no cardiac events after a negative
coronary CTA in the ED after 12- (N=481), 24- (N=368), or 47-month (N=506) follow-up.
A 2012 RCT by Hoffmann et al compared length of stay and patient outcomes in patients
evaluated with CTA versus usual care. For patients in the CTA arm of the trial, mean length of
hospital stay was reduced by 7.6 hours, and more patients were discharged directly from the ED
(47% vs 12%). There were no undetected coronary syndromes and no differences in adverse
events at 28 days. However, in the CTA arm, there was more subsequent diagnostic testing and
higher cumulative radiation exposure. Cumulative costs of care were similar between the two
groups.
A 2013 RCT by Linde et al (CATCH) compared ICA referral rate, positive predictive value
(PPV) for detection of significant coronary artery stenosis, and subsequent revascularization in
consecutive patients hospitalized at a single hospital in Denmark with suspicion of ACS but
normal or non-diagnostic electrocardiogram (ECG) and normal cardiac troponin. After
discharge, patients were randomized in a block design to coronary CTA-guided care (n=299) or
usual care (n=301). To maintain blinding, all patients underwent both coronary CTA and a
functional test (bicycle exercise-ECG and/or MPI). Mean (SD) pretest probability (using
Diamond Forrester criteria based on age, sex of the patient, and type of chest pain) was
approximately 37 in both groups. In the CTA group (n=299), patients with significant stenosis
(≥70% or >50% in the left main artery) were referred for ICA, and stenosis less than 50% was
considered nonsignificant; management of patients with intermediate stenosis was individualized
based on lesion location, stress test results, and clinical information. ICA referral rate did not
differ statistically between groups (17% with CTA vs 12% with standard care; chi-square test for
all comparisons, p=0.1). There were statistically significant between-group differences in ICAidentified significant stenosis (defined as ≥70% stenosis or reduced fractional flow reserve [FFR]
≤0.75 in intermediate stenoses [50%-70%]; 12% CTA vs 4% standard care; p=0.001);
subsequent revascularization (10% CTA vs 4% standard care; p=0.005); and, in 85 patients who
underwent ICA (49 [17%] in the CTA group and 36 [12%] in the standard care group), PPV for
detection of significant stenosis (71% CTA vs 36% control; p=0.001). Negative predictive value
(NPV) could not be calculated because not all patients underwent ICA. At three-month followup, clinical events (cardiac death, MI, unstable angina, revascularization, readmission for chest
pain) occurred in 3% of patients in the CTA group versus 5% in the standard care group (p=0.1).
Median (interquartile range) radiation exposure for protocol-specified CT calcium score plus
coronary CTA was 4.7 (3.8-6.0) mSv.
An overall assessment of the studies provides the following conclusions. Owing to the high NPV
of coronary CTA in this population of patients presenting to the ED with chest pain, the test
offers an alternative for patients and providers. Evidence obtained in the emergency setting,
similar to more extensive results among ambulatory patients, indicates a normal coronary CTA
provides a prognosis at least as good as other negative noninvasive tests. The efficiency of the
workup is improved, as patients are more quickly discharged from the emergency department
with no adverse outcomes among patients who have negative CTA examinations.
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Other important outcomes that require consideration in comparing technologies include invasive
coronary angiography rates, use of a second noninvasive test, radiation exposure, and follow-up
of any incidental findings. Although there is uncertainty accompanying the limited trial
evidence, it is reasonable to conclude that ICA rate after coronary CTA is not markedly different
from that after perfusion imaging. Two studies showed that subsequent diagnostic testing was
more frequent in patients who received CTA. Studies have differed in which treatment strategy
results in higher overall radiation exposure. Incidental findings after coronary CTA are common
and lead to further testing, but the impact of these findings on subsequent health outcomes is
uncertain.
Anomalous Coronary Arteries
Anomalous coronary arteries are an uncommon finding during angiography, occurring in
approximately 1% of coronary angiograms completed for evaluation of chest pain. However,
these congenital anomalies can be clinically important depending on the course of the anomalous
arteries. A number of case series have consistently reported that coronary CTA is able to
delineate the course of these anomalous arteries, even when conventional angiography cannot.
However, none of the studies reported results when the initial reason for the study was to identify
these anomalies, nor did any of the studies discuss impact on therapeutic decisions. Given the
uncommon occurrence of these symptomatic anomalies, it is unlikely that a prospective trial of
coronary CTA could be completed. Thus, a policy statement includes this application (i.e.,
evaluating anomalies in native coronary arteries) as medically necessary in symptomatic patients
only when conventional angiography is nondiagnostic and when the result will have an impact
on treatment.
Other Diagnostic Uses of Coronary CTA
Given its ability to define coronary artery anatomy, there are many other potential diagnostic
uses of coronary CTA including patency of coronary artery bypass grafts, in-stent restenosis,
screening, and preoperative evaluation.
•
•
•
Evaluating patency of vein grafts is generally less of a technical challenge due to vein
size and lesser motion during imaging. In contrast, internal mammary grafts may be more
difficult to image due to their small size and presence of surgical clips. Finally, assessing
native vessels distal to grafts presents difficulties, especially when calcifications are
present, due to their small size. For example, a 2008 meta-analysis including results from
64-slice scanners, reported high sensitivity 98% (95% CI, 95 to 99; 740 segments) and
specificity 97% (95% CI, 94 to 97). Other small studies have reported high sensitivity
and specificity. Lacking are multicenter studies demonstrating likely clinical benefit,
particularly given the reasonably high disease prevalence in patients evaluated.
Use of coronary CTA for evaluation of in-stent restenosis presents other technical
challenges – motion, beam hardening, and partial volume averaging. Whether these
challenges can be sufficiently overcome to obtain sufficient accuracy and impact
outcomes has not been demonstrated.
Use for screening a low-risk population was recently evaluated in 1000 patients
undergoing coronary CTA compared with a control group of 1000 similar patients.
Findings were abnormal in 215 screened patients. Over 18 months of follow-up,
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•
screening was associated with more invasive testing, statin use, but without difference in
cardiac event rates.
Coronary CTA for preoperative evaluation before noncardiac surgery has been suggested,
but evaluated only in small studies and lacking demonstrable clinical benefit.
Summary
In patients presenting to emergency settings with acute chest pain that is possibly cardiac in
origin and no known history of CAD, the net health outcome following coronary CTA appears at
least as good as that obtained following other noninvasive testing strategies. CTA can rule out
active coronary disease with a high rate of certainty in patients with low to moderate pre-test
probabilities of CAD, and is an efficient strategy in the emergency setting. Therefore, CTA may
be considered medically necessary for use in this patient population.
When anomalous coronary arteries require evaluation in symptomatic patients, coronary CTA
also is likely to be beneficial in the setting of equivocal or unsuccessful invasive angiography. It
has been demonstrated that CTA can define the anatomy of anomalous vessels when
angiography is equivocal. Thus, CTA may be considered medically necessary for evaluating
anomalous coronary arteries.
For other indications such as evaluation of patients with stable chest pain, the balance of
potential benefits and harms remains uncertain owing largely to the lack of direct comparative
evidence. A fundamental difficulty with current, albeit substantial indirect evidence surrounding
coronary CTA is that decision making has historically relied on a strategy of functional
noninvasive testing followed by invasive angiography to define anatomy. There is observational
evidence that angiography rates are higher after coronary CTA. Individual studies and systematic
reviews of coronary CTA accuracy for anatomic obstruction indicate sensitivity, specificity,
positive predictive value, and negative predictive value as good as or better than with other
noninvasive tests. Studies in representative populations that examined the frequency of repeated
testing are lacking. Noncardiac findings are frequent, but the consequences as benefits and harms
have received limited scrutiny. Evidence indicates radiation exposure with current scanners
utilizing reduction techniques is lower than with myocardial perfusion imaging.
Definitions and Processes for Determining Likelihood of Disease and Risk
Determining Pre-Test Risk Assessment for Risk Stratification
Coronary Heart Disease (CHD) Risk*
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. In general, moderate risk
will correlate with a 10-year absolute CHD risk between 10% and 20%.
CHD Risk—High*
Defined as the presence of diabetes mellitus in a patient >/= 40 years of age, peripheral arterial
disease or other coronary risk equivalents or the ten-year absolute CHD risk of greater than 20%.
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Blue Cross and Blue Shield of Alabama considers the presence of Diabetes Mellitus will
place all members in the high risk group.
Determination of Pre-test Probability for obstructive/significant Coronary Disease Based on
Chest Pain
Chest Pain Syndrome: any constellation of symptoms that the physician feels may represent a
complaint consistent with obstructive CAD. Examples of such symptoms include, but are not
exclusive to: chest pain, chest tightness, burning, dyspnea, shoulder pain, and jaw pain.
Pre-Test Probability of CAD: Once the physician determines the presence of symptoms that
may represent obstructive CAD, then the pre-test probability of CAD should be determined.
CHART 1
The following assessment is used to determine pre-test probability of coronary artery disease
based on description of the character of chest pain, member age and sex. This assessment will
define the chest pain as typical angina, atypical angina, and non-anginal chest pain. This
description then is applied to the age/sex criteria as follows:
Pre-test Probability of CAD by Age, Gender and Symptoms
Age Years
Gender
Typical/Definite
Atypical/Probable
Nonanginal
Asymptomatic
Angina Pectoris
Angina Pectoris
Chest Pain
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
Men
High
Intermediate
Intermediate
Low
Women
High
Intermediate
Intermediate
Low
High: Greater than 90%
Intermediate: Between 10%
Low: Between 5% and
Very Low: Less than 5%
pre-test probability
and 90% pre-test probability
10% pre-test probability
pre-test probability
Typical angina (definite): 1) Substernal chest pain or discomfort is 2) provoked by exertion or emotional stress and
3) relieved by rest and/or nitroglycerin.
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.
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CHART 2
Framingham Risk Assessment for Coronary Artery Disease
Framingham risk assessment is a calculation to predict the ten-year risk of heart disease in an
individual member. The calculation is made from member age, sex, most recent lipid values and
blood pressure, as well as smoking history and presence of diabetes. A sample calculator can be
found online at:
www.intmed.mcw.edu/clincalc/heartrisk.html
CHD Risk Level
Framingham Score
Low
Moderate
High
Less than 10%
Between 10% and 20%
Greater than 20%
*Based on the Framingham Risk Score calculation which can be found online at the National Heart, Lung, and
Blood Institute Web site: www.framinghamheartstudy.org/risk/index.html
Practice Guidelines and Position Statements
American Heart Association et al
ACCF/AHA/ACP/AATS/PCNA/SCAI/STS joint guidelines for management of patients with
stable ischemic heart disease were published in 2012. Guideline statements for use of coronary
CTA were divided whether used in patients without diagnosed disease or in those with known
disease, and patients’ ability to exercise:
Diagnosis Unknown
Able to Exercise (Class IIb)
“CCTA might be reasonable for patients with an intermediate pretest probability of IHD
[ischemic heart disease] who have at least moderate physical functioning or no disabling
comorbidity.” (Level of Evidence: B)
Unable to Exercise (Class IIa)
“CCTA is reasonable for patients with a low to intermediate pretest probability of IHD who are
incapable of at least moderate physical functioning or have disabling comorbidity.” (Level of
Evidence: B)
“CCTA is reasonable for patients with an intermediate pretest probability of IHD who a) have
continued symptoms with prior normal test findings, or b) have inconclusive results from prior
exercise or pharmacological stress testing, or c) are unable to undergo stress with nuclear MPI or
echocardiography.” (Level of Evidence: C)
For Patients With Known Coronary Disease
Able to Exercise (Class IIb)
“CCTA may be reasonable for risk assessment in patients with SIHD (stable ischemic heart
disease) who are able to exercise to an adequate workload but have an uninterpretable ECG.”
(Level of Evidence: B)
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Able to Exercise (Class III): No Benefit
“Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not
recommended for risk assessment in patients with SIHD who are able to exercise to an adequate
workload and have an interpretable ECG.” (Level of Evidence: C)
Unable to Exercise (Class IIa)
“Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are
unable to exercise to an adequate workload regardless of interpretability of ECG.” (Level of
Evidence: B)
“CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable
to exercise to an adequate workload regardless of interpretability of ECG.” (Level of Evidence:
C)
Unable to Exercise (Class III): No Benefit
“A request to perform either a) more than one stress imaging study or b) a stress imaging study
and a CCTA at the same time is not recommended for risk assessment in patients with SIHD.”
(Level of Evidence: C)
Regardless of Patients’Ability to Exercise (Class IIb)
“CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress
imaging or as an alternative to invasive coronary angiography when functional testing indicates a
moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown.”
(Level of Evidence: C)
Appropriate use criteria and expert consensus documents published jointly by
ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT address coronary CTA in the emergency setting.
“In the context of the emergency department evaluation of patients with acute chest
discomfort, currently available data suggest that coronary CTA may be useful in the
evaluation of patients presenting with an acute coronary syndrome (ACS) who do not
have either acute electrocardiogram (ECG) changes or positive cardiac markers.
However, existing data are limited, and large multicenter trials comparing CTA with
conventional evaluation strategies are needed to help define the role of this technology in
this category of patients.”
In 2013, ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS published appropriate
use criteria for detection and risk assessment of stable ischemic heart disease. Coronary CTA
was considered appropriate for:
• Symptomatic patients with intermediate (10%-90%) pre-test probability of coronary
artery disease (CAD) and uninterpretable ECG or inability to exercise
• Patients with newly diagnosed systolic heart failure
• Patients who have had a prior exercise ECG or stress imaging study with abnormal or
unknown results
• Patients with new or worsening symptoms and normal exercise ECG
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National Institute for Health and Care Excellence
NICE considers coronary CTA indicated for patients with stable chest pain and Agatston
coronary artery calcium score less than 400, when the pretest likelihood is between 10% and
29%.
U.S. Preventive Services Task Force Recommendations
No U.S. Preventive Services Task Force recommendations for coronary CTA have been
identified.
Key Words:
Computed tomography angiography, CTA, CT angiography
Approved by Governing Bodies:
Coronary CTA is performed using multidetector-row CT (MDCT), and multiple manufacturers
have received U.S. Food and Drug Administration (FDA) 510(k) clearance to market machines.
Current machines are equipped with at least 64 detector rows. Intravenous iodinated contrast
agents used for coronary CTA also have received FDA approval.
Benefit Application:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this
policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.
FEP does not consider investigational if FDA approved and will be reviewed for medical
necessity.
Pre-certification requirements: Effective for dates of service on or after November 1, 2007,
required when ordered by a provider in a Blue Cross and Blue Shield of Alabama’s Preferred or
Participating Network for a patient covered by Blue Cross and Blue Shield of Alabama who will
receive outpatient imaging services(s) from a Preferred Medical Doctor (PMD) or Preferred
Radiology Participating (PRP) provider.
Exceptions to the Alabama PMD and PRP pre-certification requirement: NASCO, WalMart, Blue Advantage, Flowers Foods, Inc., FEP.
In addition to the above Blue Cross and Blue Shield of Alabama PMD/PRP Network
requirement, some self-insured national account groups may require pre-certification for all
MRIs effective for dates of service on or after January 1, 2009. Please confirm during your
benefit verification process if a pre-certification is required.
Reviews to verify accuracy of pre-certification information will be conducted.
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Current Coding:
75571
75572
75573
75574
Computed tomography, heart, without contrast material, with
quantitative evaluation of coronary calcium (effective 1/1/2010)
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) (effective 1/1/2010)
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) (effective 1/1/2010)
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) (effective 1/1/2010)
Effective for dates of service on or after January 1, 2008:
Providers should NOT use the CT of chest codes to report CCT/CCTA.
CPT code:
71275
Computed tomographic angiography, chest, without contrast
material(s), followed by contrast material(s) and further sections,
including image post-processing
71275
Computed tomographic angiography, chest (noncoronary), with
contrast material(s), including noncontrast images, if performed, and
image postprocessing
Previous Coding:
HCPCS:
S8093
0145T
0146T
0147T
Computed tomographic angiography, coronary arteries, with contrast
material(s) (Code deleted effective April 1, 2006)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; cardiac structure and morphology (Code deleted
effective January 1, 2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; computed tomographic angiography of coronary
arteries (including native and anomalous coronary arteries, coronary
bypass grafts), without quantitative evaluation of coronary calcium
(Code deleted effective January 1, 2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; computed tomographic angiography of coronary
arteries (including native and anomalous coronary arteries, coronary
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0148T
0149T
0150T
0151T
0151T
0144T
0145T
0146T
0147T
bypass grafts), with quantitative evaluation of coronary calcium (Code
deleted effective January 1, 2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including native and
anomalous coronary arteries, coronary bypass grafts), without
quantitative evaluation of coronary calcium (Code deleted effective
January 1, 2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including native and
anomalous coronary arteries, coronary bypass grafts), with quantitative
evaluation of coronary calcium (Code deleted effective January 1,
2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing; cardiac structure and morphology in congenital heart
disease (Code deleted effective January 1, 2010)
Computed tomography, heart, with contrast material(s), including
noncontrast images, if performed, cardiac gating and 3d image
postprocessing, function evaluation (left and right ventricular function,
ejection-fraction and segmental wall motion) (list separately in
addition to code for primary procedure) (Code deleted effective
January 1, 2010)
Computed tomography, heart, without contrast material followed by
contrast material(s) and further sections, including cardiac gating and
3d image postprocessing, function evaluation (left and right ventricular
function, ejection-fraction and segmental wall motion) (list separately
in addition to code for primary procedure) (Code deleted effective
January 1, 2010)
Computed tomography, heart, without contrast material, including
image post processing and quantitative evaluation of coronary calcium
(Code deleted effective January 1, 2010)
Computed tomography, heart, without contrast material followed by
contrast material(s) and further sections, including cardiac gating and
3d image post processing; cardiac structure and morphology (Code
deleted effective January 1, 2010)
Computed tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass grafts),
without quantitative evaluation of coronary calcium (Code deleted
effective January 1, 2010)
Computed tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass grafts), with
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0148T
0149T
0150T
0151T
quantitative evaluation of coronary calcium (Code deleted effective
January 1, 2010)
Cardiac structure and morphology and computed tomographic
angiography of coronary arteries (including native and anomalous
coronary arteries, coronary bypass grafts), without quantitative
evaluation of coronary calcium (Code deleted effective January 1,
2010)
Cardiac structure and morphology and computed tomographic
angiography of coronary arteries (including native and anomalous
coronary arteries, coronary bypass grafts), with quantitative evaluation
of coronary calcium (Code deleted effective January 1, 2010)
Cardiac structure and morphology in congenital heart disease (Code
deleted effective January 1, 2010)
Computed tomography, heart, without contrast material followed by
contrast material(s) and further sections, including cardiac gating and
3d image post processing; function evaluation (left and right
ventricular function, ejection fraction and segmental wall motion)
(Code deleted effective January 1, 2010)
References:
1.
2.
3.
4.
5.
6.
7.
8.
Achenbach S, Moshage W, Ropers D, et al. Non-invasive, three dimensional visualization
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Aglan I, Jodocy D, Hiehs S, et al. Clinical relevance and scope of accidental extracoronary
findings in coronary computed tomography angiography: a cardiac versus thoracic FOV
study. Eur J Radiol. Apr 2010; 74(1):166-174.
Auguadro C, Manfredi M, Scalise F, et al. Multislice computed tomography for the
evaluation of coronary bypass grafts and native coronary arteries: comparison with
traditional angiography. Journal of cardiovascular medicine. Jun 2009; 10(6):454-460.
Baliga P et al. Role of CT coronary angiogram in the current era of minimally invasive
coronary angiography. J Nuc Cardiol 2007; 14(suppl):S111. Abstract 16.19.
Bamberg F, Sommer WH, Hoffmann V, et al. Meta-analysis and systematic review of the
long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced
coronary computed tomography angiography. Journal of the American College of
Cardiology. Jun 14 2011; 57(24):2426-2436.
Barriales-Villa R, Moris C. Usefulness of helical computed tomography in the identification
of the initial course of coronary anomalies, Am J Cardiol 2001; 88(6): 719.
Bateman TM, Gray RJ, Whiting JS, et al. Prospective evaluation of ultrafast cardiac
computed tomography for determination of coronary bypass graft patency, Circulation
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Berbarie RF, Dockery WD, Johnson KB, et al. Use of multislice computed tomographic
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10.
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14.
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Berrington de Gonzalez A, Mahesh M, Kim KP et al. Projected cancer risks from computed
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Bischoff B, Hein F, Meyer T, et al. Comparison of sequential and helical scanning for
radiation dose and image quality: results of the Prospective Multicenter Study on Radiation
Dose Estimates of Cardiac CT Angiography (PROTECTION) I Study. AJR. American
Journal of Roentgenology. Jun 2010; 194(6):1495-1499.
Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Contract
Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation.
TEC Assessments 2005; Volume 20, Tab 4.
Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). ContrastEnhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary
Artery Stenosis or for Evaluation of Acute Chest Pain. TEC Assessments 2006; Volume 21,
Tab 5.
Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Coronary
Computed Tomographic Angiography in the Evaluation of Patients with Acute Chest Pain.
TEC Assessments 2011; Volume 26, Tab 9.
Brenner David J and Hall Eric J. Computed tomography—An increasing source of radiation
exposure. NEJM 2007; 357: 2277-2284.
Budoff MJ, Achenbach S, Duerinckx A. Clinical utility of computed tomography and
magnetic resonance techniques for non-invasive coronary angiography, J Am Coll Cardiol
2003; 42(11): 1867-78.
Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row
coronary computed tomographic angiography for evaluation of coronary artery stenosis in
individuals without known coronary artery disease: results from the prospective multicenter
ACCURACY (Assessment by Coronary Computed Tomographic Angiography of
Individuals Undergoing Invasive Coronary Angiography) trial. Journal of the American
College of Cardiology. Nov 18 2008; 52(21):1724-1732.
Caussin C, Ohanessian A, Lancelin B, et al. Coronary plaque burden detected by multislice
computed tomography after acute myocardial infarction with near-normal coronary arteries
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Policy History:
Medical Policy Group, June 2005 (3)
Medical Policy Administration Committee, July 2005
Available for comment July 28-September 10, 2005
Medical Policy Group, June 2006 (3)
Medical Policy Group, November 2006 (3)
Medical Policy Administration Committee, January 2007
Available for comment January 10-February 23, 2007
Medical Policy Group, July 2007 (3)
Medical Policy Group, September 2007 (2)
Medical Policy Group, December 2007 (1)
Medical Policy Group, December 2008 (3)
Medical Policy Administration Committee, December 2008
Available for comment December 9, 2008-January 22, 2009
Medical Policy Group, March 2011 (2): Web site and reference update
Medical Policy Group, November 2011 (3): Updated: Policy section to include medically
necessary indications for acute chest pain in low or intermediate risk patients in the emergency
room setting, Key Points, References
Medical Policy Administration Committee, November 2011
Available for comment November 11 through December 27, 2011
Medical Policy Group, December 2011 (1)
Medical Policy Panel, November 2014
Medical Policy Group, November 2014 (3): 2014 Updates to Description, Key Points &
References; no change in policy statement
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a caseby-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i)
research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date
hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and
levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure
review) in Blue Cross and Blue Shield’s administration of plan contracts.
Page 28 of 28
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