PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
Payer
Highmark BlueCross BlueShield
Aetna
Independence BlueCross
Policy Name
Cardiac Computed Tomography (Cardiac
Cardiac CT, Coronary CT Angiography and Calcium
Clinical Appropriateness Guidelines:
CT)
Scoring
Advanced Imaging
Policy #
X-54-023
0228
N/A
RBM
National Imaging Associates
eviCore (Product line and POS dependent)
AIM Specialty Health® (AIM)
Applicable CPT
75572 75573 75574
75571 75572 75573 75574
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
Cardiac CT may be considered medically
I.
Aetna considers cardiac computed tomography (CT)
1. Congenital coronary artery anomalies
necessary for the diagnosis or risk
angiography of the coronary arteries using 64-slice
• For evaluation of suspected congenital
assessment in patients at low or
or greater medically necessary for the following
anomalies of the coronary arteries
intermediate risk, or as a pretest for
indications:
probability of coronary artery disease
A.
Rule out significant coronary stenosis in
2. Congestive heart failure/
(CAD) under the following conditions
persons with a low or intermediate pre-test
cardiomyopathy/ left ventricular
probability of coronary artery disease or
dysfunction
1. Detection of CAD in patients with chest
atherosclerotic cardiovascular disease by
• For exclusion of coronary artery disease
pain without know heart disease
Framingham risk scoring, Pooled Cohort
in patients with left ventricular ejection
• Non-acute chest pain possibly
Equations, or by American College of Cardiology
fraction <55% in whom coronary artery
representing an ischemic equivalent
(ACC) criteria (see Appendix), with any of the
disease has not been excluded as the
o Intermediate pretest probability of
following indications:
etiology of the cardiomyopathy
CAD and EKG uninterpretable or
1. Evaluation of persons with chest pain who
equivocal stress test (exercise,
cannot perform or have contraindications to
3. Evaluation of patients with suspected
perfusion, or stress echo) OR unable
exercise and pharmacological stress testing (see
coronary artery disease including those
to exercise; or
Appendix); or
with prior abnormal cardiac testing (MPI
o Low pretest probability of CAD, EKG
2. Evaluation of persons with chest pain
or stress echo)
uninterpretable or unable to exercise
presenting to the emergency department in
• Patients with abnormal MPI or stress
• Acute chest pain with suspicion of
persons without acute ECG changes or positive
echo within the preceding 60 days
acute coronary syndrome (urgent
coronary markers when an imaging stress test or
suspected to be false positive on the
presentation)
coronary angiography are being deferred as the
basis of low Coronary Heart Disease Risk
o Low or intermediate pretest
initial imaging study.
(using standard methods of risk
probability of CAD and
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CCM-100-130-A
PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
▪ Normal EKG and cardiac
B. Rule out significant coronary stenosis in persons
assessment such as the SCORE risk
biomarkers or
with a low pre-test probability of coronary artery
calculation)
▪ EKG uninterpretable or
disease or atherosclerotic cardiovascular
o In the absence of a contraindication
▪ Non-diagnostic EKG or equivocal
disease by Framingham risk scoring, Pooled Cohort
(excluding renal impairment and
cardiac biomarkers
Equations, or by American College of Cardiology
iodinated contrast agent
2. Detection of coronary artery disease in
(ACC) criteria (see Appendix) with a positive (i.e.,
hypersensitivity) patients with
other clinical scenarios
greater than or equal to 1 mm ST segment
moderate or high Coronary Heart
• Evaluation of reduced left ventricular
depression) stress test.
Disease Risk should be referred for
ejection fraction
C. Evaluation of asymptomatic persons at an
coronary arteriography; OR
• Evaluation before non-coronary cardiac
intermediate pre-test probability of coronary
• Patients with equivocal MPI or stress
surgery
heart disease or atherosclerotic cardiovascular
echo within the preceding 60 days who
3. Risk assessment post-revascularization -
disease by Framingham risk scoring or Pooled
have low or moderate Coronary Heart
Symptomatic (Ischemic Equivalent)
Cohort Equations (see Appendix) who have an
Disease Risk (using standard methods of
• Evaluation of graft patency after CABG
equivocal or uninterpretable exercise or
risk assessment such as the SCORE risk
• Prior left main coronary stent with
pharmacological stress test. Note: Current
calculation)
stent diameter equal to or greater than
guidelines from the American Heart Association
o In the absence of a contraindication
3 millimeters
recommend against routine stress testing for
(excluding renal impairment and
screening asymptomatic adults.
iodinated contrast agent
• Testing prior to electrophysiological
D.
Pre-operative assessment of persons
hypersensitivity) patients with high
procedures for anatomic mapping, or
scheduled to undergo 'high-risk" non-cardiac
Coronary Heart Disease Risk should
prior to a repeat sternotomy in re-
surgery, where an imaging stress test or invasive
be referred for coronary
operative cardiac surgery.
coronary angiography is being deferred unless
arteriography
4. Adult Congenital Heart Disease
absolutely necessary. The ACC defines high-risk
o The resulting information from the
• Assessment of anomalies of coronary
surgery as emergent operations, especially in the
CCTA should facilitate management
arterial and other thoracic
elderly, aortic and other major vascular surgeries,
decisions and not merely add a new
arteriovenous vessels
peripheral vascular surgeries, and anticipated
layer of testing
• Assessment of complex adult
prolonged surgical procedures with large fluid
• Patients at moderate coronary heart
congenital heart disease
shifts and/or blood loss involving the abdomen
disease risk (using standard methods of
5. Evaluation of Ventricular Morphology
and thorax.
risk assessment, such as the SCORE risk
and Systolic Function
E. Pre-operative assessment for planned non-
calculation) being evaluated for non-
• Evaluation of left ventricular function,
coronary cardiac surgeries including valvular heart
coronary artery cardiac surgery
following acute MI or in heart failure
disease, congenital heart disease, and pericardial
(including valvular and ascending aortic
patients when images from other non-
disease, in lieu of cardiac catheterization as the
surgery) to avoid an invasive angiogram,
invasive methods are inadequate
initial imaging study.
where all the necessary pre-operative
• Quantitative evaluation of right
F. Detection and delineation of suspected coronary
information can be obtained using
ventricular function and/or morphology
anomalies in young persons (less than 30 years of
cardiac CT
• Evaluation for suspected
age) with suggestive symptoms (e.g., angina,
• For evaluation of suspected congenital
arrhythmogenic right ventricular
syncope, arrhythmia, and exertional dyspnea
anomalies of the coronary arteries
dysplasia
without other known etiology of these symptoms
6. Evaluation of Intra- and Extracardiac
in children and adults; dyspnea, tachypnea,
Structures
wheezing, periods of pallor, irritability (episodic
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PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
• Characterization of native cardiac
crying), diaphoresis, poor feeding and failure to
valves or of suspected clinically
thrive in infants).
significant valvular dysfunction when
G.
Calculation of fractional flow reserve
images from other non-invasive
(HeartFlow FFRCT) for persons with stable, recent
methods are inadequate
onset chest pain of suspected cardiac origin and a
• Characterization of prosthetic cardiac
clinically determined intermediate (10% to 90%)
valves or suspected clinically significant
risk of coronary artery disease.
valvular dysfunction when images from
II. Aetna considers CT angiography of cardiac
other non-invasive methods are
morphology for pulmonary vein mapping
inadequate
medically necessary for the following indications:
• Evaluation of cardiac mass (suspected
A.
Evaluation of persons needing
tumor or thrombus) when images from
biventricular pacemakers to accurately identify the
other non-invasive methods are
coronary veins for lead placement.
inadequate
B.Evaluation of the pulmonary veins in persons
• Evaluation of pericardial anatomy
undergoing pulmonary vein isolation procedures
for atrial fibrillation (pre- and post-ablation
• Evaluation of pulmonary vein anatomy
procedure).
prior to radiofrequency ablation for
III. Aetna considers CT angiography medically
atrial fibrillation
necessary for preoperative assessment of the
• Noninvasive coronary vein mapping
aortic valve annulus prior to
prior to placement of biventricular
anticipated transcatheter aortic valve replacement
pacemaker
(TAVR).
• Localization of coronary bypass grafts
IV. Aetna considers cardiac CT for evaluating cardiac
and other retrosternal anatomy prior to
structure and morphology medically necessary for
reoperative chest or cardiac surgery
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;
F. Pulmonary outflow tract obstruction;
G.
Suspected or known Marfan's syndrome.
Not Covered /
Cardiac CT for all other clinical indications
I. Aetna considers cardiac CT angiography
Investigational and
and applications is considered not
experimental and investigational for persons with
Not Medically
medically necessary. There is insufficient
any of the following contraindications to the
Necessary
scientific evidence to determine whether
procedure because its effectiveness for indications
this procedure improves patient health
other than the ones listed above has not been
outcomes for other conditions.
established:
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CCM-100-130-A
PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
A.
Body mass index (BMI) greater than 40.
B. Inability to image at desired heart rate (under 80
beats/min), despite beta blocker administration.
C. Person with allergy or intolerance to iodinated
contrast material
D.
Persons in atrial fibrillation or with other
significant arrhythmia.
E. Persons with extensive coronary calcification by
plain film or with prior Angston score greater than
1,700.
Aetna considers cardiac CT angiography using less
than 64-slice scanners experimental and
investigational because the effectiveness of this
approach has not been established.
II.
Aetna considers coronary CT angiography
experimental and investigational for screening of
asymptomatic persons, evaluation
of atherosclerotic burden, evaluation of persons at
high pre-test probability of coronary artery
disease, evaluation of stent occlusion or in-stent
restenosis, evaluation of persons with an
equivocal PET rubidium study, identification
of vulnerable plaques, monitoring of atheroma
burden, and for all other indications (e.g., atrial
angiosarcoma) because its effectiveness for these
indications has not been established. Note: The
selection of CT angiography should be made
within the context of other testing modalities such
as stress myocardial perfusion images or cardiac
ultrasound results so that the resulting
information facilitates the management decision
and does not merely add a new layer of testing.
Payer Specific
Requirements
Effective Date
8/31/2015
1/20/2017
2/20/2017
Last Review/
8/31/2015
4/9/1998
7/26/2016
Original Policy Date
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CCM-100-130-A
PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
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
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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:
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PENNSYLVANIA – CORONARY CTA PRIOR-AUTHORIZATION INFORMATIONAL GUIDE
Updated March 15th, 2017
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.
“ IM Specialty Health ( IM) Ordering Physician/Provider Quick Tips for Diagnostic Imaging Management Programs.” Anthem,
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