MINNESOTA- CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated October 7th, 2016
Payer
BlueCross BlueShield Minnesota
HealthPartners
Medica
Policy Name
Cardiac Computed Tomography (Cardiac CT)
Computed tomography (CT), magnetic
Coronary Computed Tomography Angiography
resonance imaging (MRI), and positron
(CCTA) for Coronary Artery Evaluation
emission tomography (PET) scans
Policy #
X-54-001
N/A
RBM
Medicalis
eviCore (Product line and POS dependent)
Applicable CPT
75572, 75573, 75574
75574
75574
Code(s)
Applicable ICD
Not Listed
Not Listed
Not Listed
Code(s)
Covered
Cardiac CT may be considered medically
Administrative Process
Coronary computed tomography angiography
necessary for the diagnosis or risk assessment in
Providers must comply with decision support
for coronary artery evaluation is not
patients at low or intermediate risk, or as a
requirements when ordering diagnostic
investigative for the following indications:
pretest for probability of coronary artery
imaging. Approved decision support solutions
1. Evaluation for coronary artery disease (CAD)
disease (CAD) under the following conditions.
will utilize criteria to determine the
in individuals without known CAD who are
appropriateness of any diagnostic imaging
symptomatic for heart disease
1.Detection of CAD in patients with chest pain
ordered for HealthPartners' members. Please
2. Evaluation of suspected congenital anomalies
without known heart disease
see related content at right for a link to
of the coronary circulation
a. Non-acute chest pain possibly representing
HealthPartners Administrative Policy,
3. Evaluation of coronary or pulmonary venous
an ischemic equivalent
Diagnostic Imaging Provider Notification
or arterial anatomy for pre-surgical or pre-
i. Intermediate pretest probability of CAD
Program, for additional information.
procedural planning
and ECG uninterpretable or equivocal
4. Evaluation of unexplained new onset heart
stress test (exercise, perfusion, or stress
Coverage
failure for exclusion of CAD.
echo) OR unable to exercise; or
Computed Tomography (CT), Magnetic
ii. Low pretest probability of CAD, ECG
Resonance Imaging (MRI), and Positron
uninterpretable or unable to exercise
Emission Tomography (PET) scans are
b.Acute chest pain with suspicion of acute
generally covered to diagnose a medical
coronary syndrome (urgent presentation)
condition provided the decision support
i. Low or intermediate pretest probability of
process above has been followed and
CAD and
according to your plan documents.
1.Normal ECG and cardiac biomarkers or
2.ECG uninterpretable or
Diagnostic Imaging Decision Support Process
3.Non-diagnostic ECG or equivocal cardiac
HealthPartners recognizes the value of prior
biomarkers
notification/decision support for high tech
diagnostic imaging (HTDI) services. In
2.Detection of coronary artery disease in other
alignment with the Triple Aim, HealthPartners
clinical scenarios
has established the Diagnostic Imaging Prior
a. Evaluation of reduced left ventricular
Notification/ Decision Support Program. The
ejection fraction
intent of the program is to encourage a
collaborative approach to patient care
1
CCM-100-103-A
MINNESOTA- CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated October 7th, 2016
b.Evaluation before non-coronary cardiac
through the ordering provider’s use of prior
surgery
notification/decision support, ensuring that
the right exam at the right time is being
3.Risk assessment post-revascularization -
appropriately ordered for the patient.
Symptomatic (Ischemic Equivalent)
a. Evaluation of graft patency after CABG
Ordering providers are required to have a
b.Prior left main coronary stent with stent
prior notification/decision support tool in
diameter equal to or greater than 3
place when ordering one of the following
millimeters
exams for a HealthPartners member:
c. Testing prior to electrophysiological
• CT
procedures for anatomic mapping, or prior
• MRI
to a repeat sternotomy in re-operative
• MRA
cardiac surgery.
• PET
• Nuclear Medicine
4.Adult Congenital Heart Disease
a. Assessment of anomalies of coronary
Providers are able to use one of the following
arterial and other thoracic arteriovenous
types of prior notification/decision support
vessels
tools:
b.Assessment of complex adult congenital
heart disease
•
Web-based via Medicalis Consult
Portal
5.Evaluation of Ventricular Morphology and
•
Electronic Medical Records
Systolic Function
integrated
a. Evaluation of left ventricular function,
•
Build-your-own
following acute MI or in heart failure
patients when images from other non-
invasive methods are inadequate
b.Quantitative evaluation of right ventricular
function and/or morphology
c. Evaluation for suspected arrhythmogenic
right ventricular dysplasia
6.Evaluation of Intra- and Extracardiac
Structures
a. Characterization of native cardiac valves or
of suspected clinically significant valvular
dysfunction when images from other non-
invasive methods are inadequate
b.Characterization of prosthetic cardiac valves
or suspected clinically significant valvular
dysfunction when images from other non-
invasive methods are inadequate
2
CCM-100-103-A
MINNESOTA- CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated October 7th, 2016
c. Evaluation of cardiac mass (suspected tumor
or thrombus) when images from other non-
invasive methods are inadequate
d.Evaluation of pericardial anatomy
e. Evaluation of pulmonary vein anatomy prior
to radiofrequency ablation for atrial
fibrillation
f. Noninvasive coronary vein mapping prior to
placement of biventricular pacemaker
g. Localization of coronary bypass grafts and
other retrosternal anatomy prior to
reoperative chest or cardiac surgery
Not Covered /
• Cardiac CT for all other clinical indications and
Coronary computed tomography angiography
Investigational and
applications is considered not medically
for coronary artery evaluation is investigative
Not Medically
necessary. There is insufficient scientific
for all other indications, including, but not
Necessary
evidence to determine whether this
limited to, routine screening in asymptomatic
procedure improves patient health outcomes
individuals, with or without risk factors. Reliable
for other conditions.
evidence does not permit conclusions
concerning its effectiveness.
Payer Specific
Cardiac Computed Tomography (Cardiac CT) is
Medica requires that treatment decision
Requirements
typically an outpatient procedure which is only
support, utilizing one of Medica’s approved
eligible for coverage as an inpatient procedure
treatment decision support options, be
in special circumstances, including, but not
completed prior to performing CT scans.
limited to, the presence of a co-morbid
Practitioners are advised of the treatment
condition that would require monitoring in a
decision support process in their Medica
more controlled environment such as the
Provider Administrative Manual. Services with
inpatient setting.
specific coverage criteria may be reviewed
retrospectively to determine if criteria are being
met. Retrospective denial may result if criteria
are not met.
Effective Date
11/1/2015
12/19/2014
5/20/2015
Last Review/
8/2015
12/19/2014
6/1/2012
Original Policy Date
3
CCM-100-103-A
MINNESOTA- CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated October 7th, 2016
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:
1.
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.
2.
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)
3.
Diagnostic or imaging reports from previous tests (exercise stress test, echocardiography, stress echocardiography, MPI, coronary angiography, etc.)
4.
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.
5.
Examination results, including evaluation of hypertension, heart failure, cardiomyopathy, abnormal rhythm, pulmonary embolus, congenital condition, etc.
6.
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.
Current Procedural Terminology (CPT) copyright 2016.
All rights reserved. CPT® is a registered trademark of the American Medical Association (AMA). Fee schedules, relative value units, conversion factors and/or related components are not assigned by
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:
4
CCM-100-103-A
MINNESOTA- CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated October 7th, 2016
1.
“Cardiac Checklist (Health Plan).” RadMD, http://www1.radmd.com/media/459739/template-cardiac-checklist-magellan-hc-logo-4-1-2016.pdf. Accessed 25 October 2016.
2.
“AIM Specialty Health (AIM) Ordering Physician/Provider Quick Tips for Diagnostic Imaging Management Programs.” Anthem,
5
CCM-100-103-A