Coronary CTA Prior-Authorization Info Guide – Michigan

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

Payer

BlueCross BlueShield Michigan

Priority Health

Health Alliance Plan of Michigan

Policy Name

Clinical Appropriateness Guidelines:

Computerized Tomographic Angiography Coronary

eviCore Cardiac Imaging Guidelines

Advanced Imaging

Arteries (CCTA)

Appropriate Use Criteria: Imaging of the

Heart

Policy #

RAD.00035

91614-R0

CD-8~CT HEART and CCTA

RBM

AIM Specialty Health® (AIM)

eviCore (Product line and POS dependent)

http://www.aimspecialtyhealth.com/

www.evicore.com

Applicable CPT

75574

75574, 93799

75574

Code(s)

Applicable ICD

Not Listed

Various - see criteria

Not Listed

Code(s)

Covered

1.Congenital coronary artery anomalies

The following diagnostic indications for CCTA may be

A. For symptomatic individuals who have a

a. For evaluation of suspected

covered when accompanied by pre-test considerations as

very low, low, or intermediate pretest

congenital anomalies of the

well as supporting clinical data and prerequisite

probability of CAD, CCTA may be used in

coronary arteries

information:

the following situations:

1.Unable to perform either an exercise

2.Congestive Heart Failure/

A. Congenital coronary artery anomalies

or pharmacologic imaging stress test

cardiomyopathy/ left ventricular

1.For evaluation of suspected congenital anomalies of

2.Stress test (treadmill or imaging

dysfunction

the coronary arteries

stress test) is uninterpretable,

a. For exclusion of coronary artery

equivocal, or a false positive is

disease in patients with left

B. Congestive Heart Failure/ cardiomyopathy/ left

suspected

ventricular ejection fraction <55%

ventricular dysfunction

3.Replace performance of invasive

in whom coronary artery disease

1. For exclusion of coronary artery disease in patients

coronary angiogram

has not been excluded as the

with left ventricular ejection fraction <55% and low

B. For symptomatic individuals, evaluate

etiology of the cardiomyopathy

or moderate coronary heart disease risk (using

post-CABG graft patency when only graft

standard methods of risk assessment, such as the

patency is a concern and imaging of the

3.Evaluation of patients with suspected

SCORE risk calculation) in whom coronary artery

native coronary artery anatomy is not

coronary artery disease including those

disease has not been excluded as the etiology of the

needed, such as in early graft failure

with prior abnormal cardiac testing

cardiomyopathy

C. For symptomatic individuals with

(MPI or stress echo)

2. Patients with high coronary heart disease risk

unsuccessful conventional coronary

a. Patients with abnormal MPI or

should undergo cardiac catheterization

angiography

stress echo within the preceding

D. Additional Indications:

60 days suspected to be false

C. Suspected coronary artery disease in asymptomatic

1.Re-do CABG: To identify whether

positive on the basis of low

patients when Fractional Flow Reserve (FFR-CT) can be

bypass grafts are located directly

Coronary Heart Disease Risk (using

calculated in conjunction with imaging

beneath the sternum, so that

standard methods of risk

1. Patients with high-risk of CAD (SCORE) who have

alternative ways to enter the chest

assessment such as the SCORE risk

not had evaluation of coronary artery disease (MPI,

can be planned

calculation)

stress echo, cardiac PET, coronary CTA or cardiac

2.Evaluate coronary artery anomalies

i. In the absence of a

catheterization) within the preceding three (3)

and other complex congenital heart

contraindication (excluding renal

years.

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

impairment and iodinated

2.Patients with moderate or high risk of CAD (SCORE)

disease of cardiac chambers or great

contrast agent hypersensitivity)

who have a high risk occupation that would

vessels

patients with moderate or high

endanger others in the event of a myocardial

3.Anomalous coronary artery(ies)

Coronary Heart Disease Risk

infarction, (e.g. airline pilot, law-enforcement

suspected for diagnosis or to plan

should be referred for coronary

officer, firefighter, mass transit operator, bus driver)

treatment and less than age 40 with

arteriography; OR

who have not had evaluation of coronary artery

a history that includes one or more of

b.Patients with equivocal MPI or

disease (MPI, stress echo, cardiac PET, coronary CTA

the following

stress echo within the preceding

or cardiac catheterization) within the preceding

i. Persistent exertional chest pain and

60 days who have low or moderate

three (3) years.

normal stress test

Coronary Heart Disease Risk (using

3. Patients with diseases/conditions with which

ii. Full sibling(s) with history of

standard methods of risk

coronary artery disease commonly coexist and who

sudden death syndrome before age

assessment such as the SCORE risk

have not had evaluation of coronary artery disease

30 or with documented anomalous

calculation

(MPI, stress echo, cardiac PET, coronary CTA or

coronary artery

i. In the absence of a

cardiac catheterization) within the preceding three

iii. Resuscitated sudden death and

contraindication (excluding renal

(3) years:

contraindications for conventional

impairment and iodinated

i. Abdominal aortic aneurysm OR

coronary angiography

contrast agent hypersensitivity)

ii. Established and symptomatic peripheral vascular

4.Unexplained new onset of heart

patients with high Coronary

disease OR

failure

Heart Disease Risk should be

iii. Prior history of cerebrovascular accident (CVA),

5.Evaluation of newly diagnosed

referred for coronary

transient ischemia attack (TIA), or carotid

congestive heart failure or

arteriography

endarterectomy (CEA) or high grade carotid

cardiomyopathy

ii. The resulting information from

stenosis (>70%) OR

i. No prior history of coronary artery

the CCTA should facilitate

iv. Chronic renal insufficiency or renal failure

disease, the ejection fraction is less

management decisions and not

4. Patients who have undergone cardiac

than 50 percent, and low or

merely add a new layer of testing

transplantation and have had no evaluation for

intermediate risk on the pre-test

c. Patients at moderate coronary

coronary artery disease within the preceding one (1)

probability assessment AND

heart disease risk (using standard

year.

ii. No exclusions to cardiac CT

methods of risk assessment, such

5. Patients in whom a decision has been made to treat

angiography

as the SCORE risk calculation)

with interleukin 2.

iii. No cardiac catheterization, SPECT,

being evaluated for non-coronary

cardiac PET, or stress

artery cardiac surgery (including

D. Suspected coronary artery disease in symptomatic

echocardiogram has been

valvular and ascending aortic

patients who have not had evaluation of coronary artery

performed since the diagnosis of

surgery) to avoid an invasive

disease (MPI, cardiac PET, stress echo, coronary CTA or

congestive heart failure or

angiogram, where all the necessary

cardiac catheterization) within the preceding sixty (60)

cardiomyopathy

pre-operative information can be

days when Fractional Flow Reserve (FFR-CT) can be

6.Ventricular tachycardia (6 beat runs

obtained using cardiac CT

calculated in conjunction with imaging:

or greater) if CCTA will replace

For evaluation of suspected

1. Chest Pain

conventional invasive coronary

congenital anomalies of the

i. With intermediate or high pretest probability of

angiography

coronary arteries

CAD OR

7.Equivocal coronary artery anatomy

ii. With low or very low pretest probability of CAD

on conventional cardiac

and high risk of CAD (SCORE)

catheterization

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

2. Atypical symptoms: syncope, shortness of breath

8.Newly diagnosed dilated

(dyspnea), neck, jaw, arm, epigastric or back pain, or

cardiomyopathy

sweating (diaphoresis)

9.Preoperative assessment of the

i. With moderate or high risk of CAD (SCORE)

coronary arteries in patients who are

3. Other symptoms; palpitation, dizziness,

going to undergo surgery for aortic

lightheadedness, near syncope, nausea, vomiting,

dissection, aortic aneurysm, or

anxiety, weakness, fatigue etc.

valvular surgery if CCTA will replace

i. With high risk of CAD (SCORE)

conventional invasive coronary

4.Patients with any cardiac symptom who have

angiography”

diseases/conditions with which coronary artery

10. Vasculitis/Takayasu’s/Kawasaki’s

disease commonly coexists such as:

disease

i. Diabetes mellitus OR

11. Cardiac Trauma: Chest CTA

ii. Abdominal aortic aneurysm OR

(CPT®71275) and CCTA (CPT®75574)

iii. Established and symptomatic peripheral vascular

are useful in detecting aortic and

disease OR

coronary injury and can help in the

iv. Prior history of cerebrovascular accident (CVA),

evaluation of myocardial and

transient ischemia attack (TIA), or carotid

pericardial injury

endarterectomy (CEA) or high grade carotid

stenosis (>70%) OR

v. Chronic renal insufficiency or renal failure

5. Patients who have undergone cardiac

transplantation.

6.Patients in whom a decision has been made to treat

with interleukin 2.

E. Patients with suspected CAD and abnormal exercise

treadmill test (performed without imaging) with low or

moderate coronary heart disease risk (using standard

methods of risk assessment such as the SCORE risk

calculation) when Fractional Flow Reserve (FFR-CT) can

be calculated in conjunction with imaging

1.Abnormal finding on an exercise treadmill test

include chest pain, ST segment change, abnormal BP

response or complex ventricular arrhythmias.

F. Patients with abnormal MPI or stress echo within the

preceding 60 days suspected to be false positive on the

basis of low coronary heart disease risk (using standard

methods of risk assessment such as the SCORE risk

calculation)

1.In the absence of a contraindication (excluding renal

impairment and iodinated contrast agent

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

hypersensitivity), patients with moderate or high

coronary heart disease risk should be referred for

coronary arteriography

G. Patients with equivocal MPI or stress echo within the

preceding 60 days who have low or moderate coronary

heart disease risk (using standard methods of risk

assessment such as the SCORE risk calculation)

1.In the absence of a contraindication (excluding renal

impairment and iodinated contrast agent

hypersensitivity), patients with high coronary heart

disease risk should be referred for coronary

arteriography

2.The resulting information from the CCTA should

facilitate management decisions and not merely add

a new layer of testing

H. Patients at moderate coronary heart disease risk (using

standard methods of risk assessment, such as the

SCORE risk calculation) being evaluated for non-

coronary artery cardiac surgery (including valvular and

ascending aortic surgery) to avoid an invasive

angiogram, where all the necessary pre-operative

information can be obtained using cardiac CT.

Not Covered /

• Irregular heart rhythms

Investigational and

• Multifocal Atrial Tachycardia (MAT)

Not Medically

• Inability to lie flat

Necessary

• Body mass index of 40 or more

• Inability to obtain a heart rate less than

65 beats per minute after beta-blockers

• Inability to hold breath for at least 8

seconds

• Renal Insufficiency

• Asymptomatic patients and routine use

in the evaluation of the coronary arteries

following heart transplantation

• CCTA should not be performed if there is

extensive coronary calcification (calcium

score >1000)

• Evaluation of coronary stent patency

(metal artifact limits accuracy)

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

• Evaluation of left ventricular function

following myocardial infarction or in

chronic heart failure

• Evaluation of patients with postoperative

native or prosthetic cardiac valves who

have technically limited

echocardiograms, MRI or TEE. Patients

with indeterminate echocardiogram

should undergo MUGA (CPT®78472 or

CPT®78494) or cardiac MRI

• First test in evaluating symptomatic

patients (e.g. chest pain)

• Irregular heart rhythms

• High pre-test probability for CAD—

rather, these patients should undergo

conventional coronary angiography,

especially if an interventional procedure

(e.g., PCI) is anticipated

• Identification of plaque composition and

morphology

• Myocardial perfusion and viability

studies

• Preoperative assessment for non-

cardiac, nonvascular surgery

• Repeat or routine follow-up of CAD with

CCTA

There is insufficient evidence to support

routine use of Coronary Computed

Tomography Angiography (CCTA) in the

evaluation of the coronary arteries

following heart transplantation.

Payer Specific

•

CCTA exams are not covered by most

•

CCTA exams are not covered by most healthcare

1.Must be ordered by a HAP/AHL Affiliated

Requirements

healthcare insurers as a screening

insurers as a screening study, in the absence of signs,

or Contracted Physician

study, in the absence of signs,

symptoms or known disease

2. Must be performed at a HAP/AHL

symptoms or known disease

•

Selection of the optimal diagnostic work-up for cardiac

Affiliated or Contracted Facility.

•

Selection of the optimal diagnostic

evaluation should be made within the context of other

3.Must be authorized be a HAP Medical

work-up for cardiac evaluation should

available studies (which include treadmill stress test,

Director or designee, except for Medicare

be made within the context of other

stress myocardial perfusion imaging, stress

Complementary members with Medicare

available studies (which include

echocardiography, cardiac MRI, cardiac PET imaging

primary and HAP or AHL secondary.

treadmill stress test, stress myocardial

and invasive cardiac/coronary angiography), so that

perfusion imaging, stress

the resulting information facilitates patient

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

echocardiography, cardiac MRI,

management decisions and does not merely add a new

cardiac PET imaging and invasive

layer of testing

cardiac/coronary angiography), so

that the resulting information

facilitates patient management

decisions and does not merely add a

new layer of testing

Effective Date

10/31/2016

12/1/2015

3/18/2016

Last Review/

7/26/2016

11/11/2015

12/31/2015

Original Policy Date

3/30/2005

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.

CCM-100-117-A

MICHIGAN - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated November 18^th, 2016

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.

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-100-117-A