Coronary CTA Prior-Authorization Info Guide – Illinois

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

Payer

BlueCross BlueShield Illinois

Aetna

Cigna

Policy Name

Computed Tomography Angiography

Cardiac CT, Coronary CT Angiography and Calcium

Cigna Medical Coverage Policies - Radiology

(CTA)

Scoring

Cardiac Imaging

Policy #

RAD604.007

0228

RBM

AIM Specialty Health® (AIM)

eviCore (Product line and POS dependent)

http://www.aimspecialtyhealth.com/

www.evicore.com

Applicable CPT

75574

Code(s)

Applicable ICD

Not Listed

E08.00 - E09.9

Not Listed

Code(s)

E10.10 - E13.9

Not all-inclusive

I37.0 - I37.9

M30.3

Q21.3

Q26.0 - Q26.9

Q87.40 - Q87.43

R94.39

Covered

• Contrast-enhanced computed

I. Aetna considers cardiac computed tomography

1. For symptomatic individuals who have a very

tomography (CT) angiography (CTA) for

(CT) angiography of the coronary arteries using 64-

low, low, or intermediate pretest probability

evaluation of patients without known

slice or greater medically necessary for the

of CAD, CCTA may be used in the following

coronary artery disease (CAD) who

following indications:

situations:

present with acute chest pain in the

a. Unable to perform either an exercise or

emergency room or emergency

Rule out significant coronary stenosis in

pharmacologic imaging stress test

department setting may be considered

persons with a low or intermediate pre-test

b.Stress test (treadmill or imaging stress

medically necessary.

probability of coronary artery disease or

test) is uninterpretable, equivocal, or a

atherosclerotic cardiovascular disease by

false positive is suspected

• Contrast-enhanced CTA for evaluation

Framingham risk scoring, Pooled Cohort

c. Replace performance of invasive coronary

of patients with suspected ischemic

Equations, or by American College of Cardiology

angiogram

heart disease, who meet guideline

(ACC) criteria (see Appendix), with any of the

2. For symptomatic individuals, evaluate post-

criteria for a noninvasive test in the

following indications:

CABG graft patency when only graft patency is

outpatient setting may be considered

1. Evaluation of persons with chest pain who

a concern and imaging of the native coronary

medically necessary (refer to NOTE

cannot perform or have contraindications to

artery anatomy is not needed, such as in early

1 below).

exercise and pharmacological stress testing; or

graft failure.

2. Evaluation of persons with chest pain

3. For symptomatic individuals with

NOTE 1: A noninvasive test should be

presenting to the emergency department in

unsuccessful conventional coronary

performed on patients with at least

persons without acute ECG changes or positive

angiography.

intermediate risk for coronary artery

coronary markers when an imaging stress test

4. Re-do CABG: To identify whether bypass

disease (10%-90% risk by standard risk

or coronary angiography are being deferred as

grafts are located directly beneath the

prediction instruments/pre-test

the initial imaging study.

sternum, so that alternative ways to enter the

probability assessments). The choice of

chest can be planned.

test will depend on:

Rule out significant coronary stenosis in

persons with a low pre-test probability of coronary

CCM-100-101-A

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

Interpretability of the

artery disease or atherosclerotic cardiovascular

5. Evaluate coronary artery anomalies and other

electrocardiogram;

disease by Framingham risk scoring, Pooled Cohort

complex congenital heart disease of cardiac

Ability to exercise; and

Equations, or by American College of Cardiology

chambers or great vessels

Presence of comorbidities

(ACC) criteria (see Appendix) with a positive (i.e.,

6. Anomalous coronary artery(ies) suspected for

greater than or equal to 1 mm ST segment

diagnosis or to plan treatment and less than

• Contrast-enhanced CTA for evaluation

depression) stress test.

age 40 with a history that includes one or

of anomalous (native) coronary

more of the following

arteries in patients in whom they are

Evaluation of asymptomatic persons at an

a. Persistent exertional chest pain and

suspected may be considered

intermediate pre-test probability of coronary heart

normal stress test

medically necessary when

disease or atherosclerotic cardiovascular disease by

b.Full sibling(s) with history of sudden death

conventional angiography is

Framingham risk scoring or Pooled Cohort

syndrome before age 30 or with

unsuccessful or equivocal and when

Equations (see Appendix) who have an equivocal or

documented anomalous coronary artery

the results will impact treatment

uninterpretable exercise or pharmacological stress

c. Resuscitated sudden death and

test.

contraindications for conventional

coronary angiography

Pre-operative assessment of persons

7. Unexplained new onset of heart failure

scheduled to undergo 'high-risk" non-cardiac surgery,

8. Evaluation of newly diagnosed congestive

where an imaging stress test or invasive coronary

heart failure or cardiomyopathy

angiography is being deferred unless absolutely

a. No prior history of coronary artery

necessary. The ACC defines high-risk surgery as

disease, the ejection fraction is less than

emergent operations, especially in the elderly, aortic

50 percent, and low or intermediate risk

and other major vascular surgeries, peripheral

on the pre-test probability assessment

vascular surgeries, and anticipated prolonged surgical

AND

procedures with large fluid shifts and/or blood loss

b.No exclusions to cardiac CT angiography

involving the abdomen and thorax.

c. No cardiac catheterization, SPECT, cardiac

PET, or stress echocardiogram has been

Pre-operative assessment for planned non-

performed since the diagnosis of

coronary cardiac surgeries including valvular heart

congestive heart failure or

disease, congenital heart disease, and pericardial

cardiomyopathy

disease, in lieu of cardiac catheterization as the initial

9. Ventricular tachycardia (6 beat runs or

imaging study.

greater) if CCTA will replace conventional

invasive coronary angiography

Detection and delineation of suspected

10. Equivocal coronary artery anatomy on

coronary anomalies in young persons (less than 30

conventional cardiac catheterization

years of age) with suggestive symptoms (e.g., angina,

11. Newly diagnosed dilated cardiomyopathy

syncope, arrhythmia, and exertional dyspnea without

12. Preoperative assessment of the coronary

other known etiology of these symptoms in children

arteries in patients who are going to undergo

and adults; dyspnea, tachypnea, wheezing, periods of

surgery for aortic dissection, aortic aneurysm,

pallor, irritability (episodic crying), diaphoresis, poor

or valvular surgery if CCTA will replace

feeding and failure to thrive in infants).

conventional invasive coronary angiography

13. Vasculitis/Takayasu‘s/Kawasaki‘s disease

CCM-100-101-A

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

II. Aetna considers CT angiography of cardiac

morphology for pulmonary vein mapping medically

necessary for the following indications:

Evaluation of persons needing biventricular

pacemakers to accurately identify the coronary veins

for lead placement.

Evaluation of the pulmonary veins in

persons undergoing pulmonary vein isolation

procedures for atrial fibrillation (pre- and post-

ablation procedure).

III.

Aetna considers CT angiography medically

necessary for preoperative assessment of the

aortic valve annulus prior to

anticipated transcatheter aortic valve replacement

(TAVR).

IV.

Aetna considers cardiac CT for evaluating

cardiac structure and morphology medically

necessary for the following indications:

A. Anomalous pulmonary venous drainage;

B. Evaluation of other complex congenital

heart diseases;

C. Evaluation of sinus venosum atrial-septal

defect;

D. Kawasaki's disease;

E. Person scheduled or being evaluated for

surgical repair of tetralogy of Fallot or

other congenital heart diseases;

Pulmonary outflow tract obstruction;

Suspected or known Marfan's syndrome.

Not Covered /

• Contrast-enhanced CTA for coronary

1.Aetna considers cardiac CT angiography

1. Irregular heart rhythms (e.g., atrial

Investigational and

artery evaluation is considered

experimental and investigational for persons with

fibrillation/flutter, frequent irregular

Not Medically

experimental, investigational and/or

any of the following contraindications to the

premature ventricular contractions or

Necessary

unproven for all other indications,

procedure because its effectiveness for indications

premature atrial contractions, and high grade

including but not limited to:

other than the ones listed above has not been

heart block)

established:

2. Multifocal Atrial Tachycardia (MAT)

CCM-100-101-A

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

o Screen asymptomatic individuals

3. Inability to lie flat

for CAD; OR

A. Body mass index (BMI) greater than 40.

4. Body mass index of 40 or more

o Evaluate individuals with cardiac

B. Inability to image at desired heart rate (under

5. Inability to obtain a heart rate less than 65

risk factors in lieu of cardiac

80 beats/min), despite beta blocker

beats per minute after beta-blockers

evaluation and standard non-

administration.

6. Calcium (Agatston) score of 1000 or more

invasive cardiac testing; OR

C. Person with allergy or intolerance to iodinated

7. Inability to hold breath for at least 8 seconds

o Evaluate individuals for any other

contrast material

8. Renal Insufficiency

indication not listed above,

D. Persons in atrial fibrillation or with other

9. Asymptomatic patients and routine use in the

including but not limited to high

significant arrhythmia.

evaluation of the coronary arteries following

or low pretest probability (low

E. Persons with extensive coronary calcification

heart transplantation

risk defined as <10% and high risk

by plain film or with prior Angston score

10. Evaluation of coronary stent patency (metal

as >90%) of CAD.

greater than 1,700.

artifact limits accuracy)

11. Evaluation of left ventricular function

• Coronary CTA performed using a multi-

2. Aetna considers cardiac CT angiography using less

following myocardial infarction or in chronic

detector row computed tomography

than 64-slice scanners experimental and

heart failure

scanner with less than 64-slice scanner

investigational because the effectiveness of this

12. Evaluation of patients with postoperative

is considered experimental,

approach has not been established.

native or prosthetic cardiac valves who have

investigational and/or unproven.

technically limited echocardiograms, MRI or

3.Aetna considers coronary CT angiography

TEE.

• The use of noninvasive fractional flow

experimental and investigational for screening of

13. First test in evaluating symptomatic patients

reserve (FFR) CT simulation to evaluate

asymptomatic persons, evaluation

(e.g. chest pain)

and assess coronary blood flow

of atherosclerotic burden, evaluation of persons at

14. Irregular heart rhythms (e.g., atrial

quantity and velocity for any cardiac

high pre-test probability of coronary artery disease,

fibrillation/flutter, frequent irregular

condition, with or without a prior

evaluation of stent occlusion or in-stent restenosis,

premature ventricular contractions or

coronary CTA, is considered

evaluation of persons with an equivocal PET

premature atrial contractions, and high grade

experimental, investigational and/or

rubidium study, identification of vulnerable

heart block)

unproven.

plaques, monitoring of atheroma burden, and for

15. High pre-test probability for CAD—rather,

all other indications (e.g., atrial

these patients should undergo conventional

angiosarcoma) because its effectiveness for these

coronary angiography, especially if an

indications has not been established.

interventional procedure (e.g., PCI) is

anticipated

16. Identification of plaque composition and

morphology

17. Myocardial perfusion and viability studies

18. Preoperative assessment for non-cardiac,

nonvascular surgery

19. Repeat or routine follow-up of CAD with

CCTA

20. There is insufficient evidence to support

routine use of Coronary Computed

Tomography Angiography (CCTA) in the

CCM-100-101-A

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

evaluation of the coronary arteries following

heart transplantation.

Payer Specific

Requirements

Effective Date

8/15/2016

4/15/2016

5/12/2016

Last Review/

2/15/2007

4/9/1998

2/19/2016

Original Policy Date

SUGGESTED DOCUMENTATION TO NAVIGATE PRE-AUTHORIZATION

For instances when the indication is medically necessary, clinical evidence is required to determine medical necessity. For instances when the indication is investigational, you

may submit additional information to the Prior Authorization Department. The following documentation is recommended in order to ensure that pre-authorization can be

secured in a timely and efficient manner:

Medical chart notes - all notes from the patient chart related to the requested procedure, including patient’s current cardiac status/ symptoms, cardiac

factors, and indications.

Relevant patient information, including:

▪ Patient age, height, weight, and BMI

▪ Family history of heart problems (including relationship to member, age at diagnosis, type of event, etc.)

▪ Medical history (e.g. diabetes, hypertension, stroke arrhythmia, etc.)

▪ Cardiac risk factors

▪ Previous cardiac treatments, surgeries, or interventions

▪ Problems with exercise capacity

▪ Ordering provider information

▪ Imaging provider information

▪ Imaging exam(s) being requested (body part, right, left, or bilateral)

▪ Patient diagnosis (suspected or confirmed)

Diagnostic or imaging reports from previous tests (exercise stress test, echocardiography, stress echocardiography, MPI, coronary angiography, etc.)

Symptom history (onset, course, new or changing symptoms) related to all pertinent cardiac conditions, such as heart muscle/ valvular disease, structural

abnormality, infection, exposure to toxins/ chemotherapy, etc.

Examination results, including evaluation of hypertension, heart failure, cardiomyopathy, abnormal rhythm, pulmonary embolus, congenital condition, etc.

Any other documentation that supports the need for the procedure

DISCLAIMER: The information provided in this document is general information only and is not provided as legal advice, nor is it advice about how to code, complete, or submit any particular claim for

payment for health care services or goods. This information provides only an overview of HeartFlow’s understanding of current coverage policies for a select number of payers, and may not provide

all the information necessary to understand a particular patient’s benefits or payers coverage policies and prior authorization requirements. The information provided may not be comprehensive or

complete. It is the responsibility of the health care provider, such as a hospital or a physician to verify coverage and prior authorization requirements, submit complete, accurate and appropriate bills

or claims for payment that comply with applicable laws and regulations and third-party payer requirements, and to determine the appropriate codes, charges, and modifiers that the provider uses for

those purposes. Third-party payers may have policies and coding requirements that differ from those described here, and such policies can change over time.

HeartFlow disclaims any responsibility for claims submitted by health care physicians or others. Physicians should check and verify current policies and requirements with the payer for each patient.

HeartFlow endorses the best practice that all coding and billing submissions to payers be truthful and not misleading, and that providers make full disclosures to the payer about how the service has

been used. HeartFlow cannot guarantee success in obtaining payment for products and services.

CCM-100-101-A

ILLINOIS - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated October 6^th, 2016

the AMA, are not part of CPT coding, and the AMA is not recommending their use.

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) is maintained by the National Center for Health Statistics and the Centers for Medicare and Medicaid

Services.

References:

“Cardiac Checklist (Health Plan).” RadMD, http://www1.radmd.com/media/459739/template-cardiac-checklist-magellan-hc-logo-4-1-2016.pdf. Accessed 25October 2016.

“AIM Specialty Health (AIM) Ordering Physician/Provider Quick Tips for Diagnostic Imaging Management Programs.” Anthem,

https://www11.anthem.com/provider/nh/f5/s2/t0/pw_ad087257.pdf. Accessed 25 October 2016.

CCM-100-101-A