Coronary CTA Prior-Authorization Info Guide – New York

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

Payer

United Healthcare

Excellus BlueCross BlueShield

Emblem Health

Policy Name

Physician Guidelines

Cardiac/Coronary Computed Tomographic

eviCore Cardiac Imaging Guidelines

Current, Evidence-based Recommendations

Angiography (Cardiac/Coronary CTA):

Regarding Imaging

Contrast-Enhanced

Policy #

Criteria for Imaging V2.0.2016

6.01.34

RBM

eviCore (Product line and POS dependent)

www.evicore.com

Applicable CPT

75574

75572 75573 75574

Code(s)

Applicable ICD

Not Listed

Numerous

Not Listed

Code(s)

Not all-inclusive

Covered

Computerized Tomographic Angiography

Based upon our criteria and review of the

Emblem Health has not made their Coronary CTA

Coronary Arteries (CCTA) may be considered

peer-reviewed literature, cardiac computed

medical policy public.

medically necessary for the following

tomographic angiography (CTA), using at

indications:

least a 64-slice CT scanner, is considered

Prior Approval requests must be made in one of

medically appropriate for any of the

three ways (more info at link here):

A. Evaluation of known coronary artery disease

following:

• Online: Visit www.evicore.com. To submit

(CAD) [One of the following]

online prior approval requests, the ordering

1. CAD documented by prior imaging stress

C. Cardiac CT angiography:

physician must be a registered user. To

test, cardiac catheterization, cardiac CT

angiogram, coronary revascularization,

1. Evaluation of known coronary artery

www.evicore.com and click the "Register"

carotid stenosis or stroke, peripheral artery

disease (CAD) documented by prior

button.

disease, or aortic aneurysm [One of the

imaging stress test, cardiac catheterization,

• By phone: Call 1-866-417-2345 for HIP,

following]

cardiac CT angiogram, coronary

EmblemHealth CompreHealth EPO,

a. New chest pain or shortness of breath

revascularization, carotid stenosis or

EmblemHealth Medicare HMO, GHI HMO and

[One of the following]

stroke, peripheral artery disease or aortic

Vytra plan members. Call 1-800-835-7064

i. Prior coronary artery bypass grafting

aneurysm:

for EmblemHealth Medicare PPO plan

and there are no exclusions to cardiac

a. New chest pain or shortness of

members.

CT angiography

breath with prior coronary artery bypass

• By fax: The fax option applies only to prior

ii. Medicare only - an imaging stress

grafting and no exclusions to cardiac CT

approval requests for cardiac imaging codes.

test or catheterization has not been

angiography; or

You may fax these requests to 1-888-622-

performed nor is planned to evaluate

b. To identify whether bypass grafts are

7369. With your fax submission, please

symptoms and there are there are no

located directly beneath the sternum, so

include an EmblemHealth-specific cardiac

exclusions to cardiac CT angiography

that alternative ways to enter the chest can

imaging clinical request form. This form is

b. No new chest pain or shortness of

be planned.

available at www.evicore.com.

breath

c. No new chest pain or shortness of

i. A left main stent of three mm or

breath and a left main stent of 3 mm or

Emblem Health medical policy on CTA likely follows

more is present and there are no

more is present and there are no exclusions

the eviCore Cardiac Imaging Guidelines in which

exclusions to cardiac CT angiography

to cardiac CT angiography.

CCM-100-129-A

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

2. CAD documented by a prior calcium

2. Evaluation of known coronary artery

coronary CTA is considered medically necessary for

score less than 400

disease (CAD) documented by a prior

the following:

a. Evaluation of new chest pain or

calcium scores less than 400:

dyspnea, no imaging stress test is

a. Evaluation of new chest pain or

1.For symptomatic individuals who have a very low,

planned, and there are no exclusions to

dyspnea, no imaging stress test is planned,

low, or intermediate pretest probability of CAD*,

cardiac CT angiography

and there are no exclusions to cardiac CT

CCTA may be used in the following situations:

angiography.

o Unable to perform either an exercise or

B. Evaluation of newly diagnosed congestive

3. Evaluation of suspected coronary artery

pharmacologic imaging stress test

heart failure or cardiomyopathy [Both of the

disease with new or changed chest pain or

o Stress test (treadmill or imaging stress test) is

following]

shortness of breath.

uninterpretable, equivocal, or a false positive is

1. No prior history of coronary artery

4. Unable to perform either an exercise or

suspected

disease, the ejection fraction is less than 50

pharmacologic imaging stress test.

o Replace performance of invasive coronary

percent, and low or intermediate risk on

5. Stress test (treadmill or imaging stress

angiogram

the pre-test probability

test) is normal, uninterpretable, equivocal,

2. For symptomatic individuals, evaluate post-CABG

assessment

or a false positive is suspected.

graft patency when only graft patency is a

2. No exclusions to cardiac CT angiography

6. Replace performance of invasive

concern and imaging of the native coronary artery

3. No cardiac catheterization, SPECT,

coronary angiogram.

anatomy is not needed, such as in early graft

cardiac PET, or stress echocardiogram has

7. Abnormal treadmill with normal imaging.

failure.

been performed since the diagnosis of

8. Prior calcium scores less than 400.

3. For symptomatic individuals with unsuccessful

congestive heart failure or cardiomyopathy

9. Prior coronary artery bypass grafting;

conventional coronary angiography.

urgent presentation of acute symptoms can

C. Evaluation of suspected coronary artery

proceed to cardiac CT angiography without

Additional Indications:

disease [One of the following]

stress testing of any type and regardless of

1.Re-do CABG

1. New or changed chest pain or shortness of

pretest probability.

o To identify whether bypass grafts are located

breath

10. Evaluation of suspected coronary artery

directly beneath the sternum, so that

a. Contraindication to a routine exercise

disease in patients prior to non-coronary

alternative ways to enter the chest can be

stress test (inability to exercise, diabetes,

cardiac surgery; and

planned.

digoxin use, poor heart rate response,

a. Intermediate risk on the pre-test

2.Evaluate coronary artery anomalies and other

Wolff-Parkinson-White syndrome,

probability assessment and no exclusion to

complex congenital heart disease of cardiac

complete left bundle branch block, one

cardiac CT angiography.

chambers or great vessels

mm or more ST-J depression with

11. Evaluation of suspected coronary artery

o Report CPT®75574 for evaluating coronary

horizontal or downsloping ST segments

disease with suspected anomalous

artery anomalies.

80 msec after the J point, or ventricular

coronary artery; and

o Report CPT®75573 for congenital heart disease

paced rhythm)

a. Cardiac catheterization was

• To evaluate the great vessels, Chest CTA

i. Low or intermediate risk on the pre-

performed, all coronary arteries were not

(71275) can be performed instead of CCTA or

test probability assessment AND

identified, and no exclusion to cardiac CT

in addition to CCTA For anomalous pulmonary

ii. No exclusions to cardiac CT

angiography.

venous return, can add CT abdomen and

angiography

12. New onset of congestive heart failure

pelvis with contrast (CPT®74177)

b. No contraindications to a routine

without known coronary artery disease to

3.Anomalous coronary artery(ies) suspected for

exercise stress test [One of the following]

assess coronary arteries; and

diagnosis or to plan treatment and less than age

i. Normal routine exercise stress

a. Low or intermediate risk on the pre-

40 with a history that includes one or more of the

test probability assessment, the ejection

following

CCM-100-129-A

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

01.New or worsening chest pain or

fraction is less than 50% and no exclusion

o Persistent exertional chest pain and normal

shortness of breath, cardiac

to cardiac CT angiography.

stress test

catheterization is not planned and

13. Ventricular tachycardia (6 beat runs or

o Full sibling(s) with history of sudden death

there are no exclusions to cardiac CT

greater) if CCTA will replace conventional

syndrome before age 30 or with documented

angiography

invasive coronary angiography.

anomalous coronary artery

ii. Routine exercise stress test

14. Equivocal coronary artery anatomy on

o Resuscitated sudden death and

abnormal or not performed

conventional cardiac catheterization;

contraindications for conventional coronary

01.Intermediate risk on the pre-test

15. Preoperative assessment of the

angiography

probability assessment and no

coronary arteries in patients who are going

4.Unexplained new onset of heart failure

exclusions to cardiac CT angiography

to undergo surgery for aortic dissection,

5.Evaluation of newly diagnosed congestive heart

2. Prior imaging stress test [One of the

aortic aneurysm, or valvular surgery if CCTA

failure or cardiomyopathy

following]

will replace conventional invasive coronary

o No prior history of coronary artery disease, the

a. Normal imaging stress test [All of the

angiography;

ejection fraction is less than 50 percent, and low

following]

16. Vasculitis/Takayasu’s/Kawasaki’s

or intermediate risk on the pre-test probability

i. New or worsening chest pain or

disease.

assessment AND

shortness of breath AND

o No exclusions to cardiac CT angiography

ii. Cardiac catheterization is not

o No cardiac catheterization, SPECT, cardiac PET,

planned AND

or stress echocardiogram has been performed

iii. No exclusions to cardiac CT

since the diagnosis of congestive heart failure or

angiography

cardiomyopathy

b. Abnormal imaging stress test

6. Ventricular tachycardia (6 beat runs or greater) if

documenting ANY of the following if no

CCTA will replace conventional invasive coronary

exclusions to cardiac CT angiography are

angiography.

present [One of the following]

7. Equivocal coronary artery anatomy on

i. Normal treadmill with reversible

conventional cardiac catheterization

perfusion abnormality or wall motion

8. Newly diagnosed dilated cardiomyopathy

abnormality including transient

9. Preoperative assessment of the coronary arteries

ischemic dilatation

in patients who are going to

ii. Equivocal

undergo surgery for aortic dissection, aortic

iii. Abnormal treadmill with normal

aneurysm, or valvular surgery if

imaging

CCTA will replace conventional invasive coronary

3. Evaluation for non-coronary cardiac

angiography”

surgery

10. Vasculitis/Takayasu’s/Kawasaki’s disease

a. Intermediate risk on the pre-test

probability assessment and no exclusions

to cardiac CT angiography

4. Suspected anomalous coronary artery

a. Cardiac catheterization was performed, all

coronary arteries were not identified, and no

exclusions to cardiac CT angiography

CCM-100-129-A

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

Not Covered /

The following is a list of exclusion criteria for

The following are examples of

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

Investigational and

CCTA:

contraindications to the use of cardiac CT

fibrillation/flutter, frequent

Not Medically

• Atrial fibrillation

angiography:

irregular premature ventricular contractions or

Necessary

• Multifocal atrial tachycardia (MAT)

A. Atrial fibrillation;

premature atrial

• Inability to lie flat

B. Multifocal atrial tachycardia;

contractions, and high grade heart block)

• Body mass index of 40 or more

C. Inability to lie flat;

2. Multifocal Atrial Tachycardia (MAT)

• Inability to obtain a heart rate less than 65

D. Body mass index of greater than 40;

3. Inability to lie flat

beats per minute after betablockers

E. Inability to obtain a heart rate of less

4. Body mass index of 40 or more

than 65 beats per minute after beta

5. Inability to obtain a heart rate less than 65 beats

• Calcium (Agatston) score of 1000 or more

blockers;

per minute after beta-blockers

• Inability to hold breath for at least 8 seconds

F. Calcium score of greater than 1000;

6. Inability to hold breath for at least 8 seconds

Renal insufficiency

G. Inability to breath hold for greater

7. Renal Insufficiency

than 8 seconds;

8. Asymptomatic patients and routine use in the

H. Renal insufficiency (creatinine

evaluation of the coronary arteries following heart

greater than 1.8 mg/dl).

transplantation

9. CCTA should not be performed if there is

extensive coronary calcification (calcium score

>1000)

10. Evaluation of coronary stent patency (metal

artifact limits accuracy)

11. Evaluation of left ventricular function following

myocardial

infarction or in chronic heart failure

12. 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.

13. First test in evaluating symptomatic patients

(e.g. chest pain)

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

fibrillation/flutter, frequent irregular premature

ventricular contractions or premature atrial

contractions, and high grade heart block)

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

patients should undergo conventional coronary

angiography, especially if an

interventional procedure (e.g., PCI) is anticipated

16. Identification of plaque composition and

morphology

17. Myocardial perfusion and viability studies

CCM-100-129-A

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

18. Preoperative assessment for non-cardiac,

nonvascular surgery

19. Repeat or routine follow-up of CAD with CCTA

Payer Specific

Requirements

Effective Date

9/16/2016

6/16/2005

3/18/2016

Last Review/

4/21/2016

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.

CCM-100-129-A

NEW YORK - CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE

Updated March 14^th, 2017

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.

“ IM Specialty Health ( IM) 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-100-129-A