Download Contrast-Enhanced Computed Tomographic Angiography (CTA) for

Cardiac Computed Tomographic Angiography
(CCTA)
DESCRIPTION
Contrast-enhanced computed tomography angiography (CTA) is a noninvasive imaging test
that requires the use of intravenously administered contrast material and high-resolution,
high-speed CT machinery to obtain detailed volumetric images of blood vessels. CTA can be
applied to image blood vessels throughout the body; however, for the coronary arteries,
several technical challenges must be overcome to obtain high-quality diagnostic images.
First, very short image acquisition times are necessary to avoid blurring artifacts from the
rapid motion of the beating heart. In some cases, premedication with beta-blocking agents is
used to slow the heart rate below approximately 60–65 beats per minute to facilitate adequate
scanning, and electrocardiographic triggering or gating (retrospective or prospective) is used
to obtain images during diastole when motion is reduced. Second, rapid scanning is also
helpful so that the volume of cardiac images can be obtained during breath-holding. Third,
very thin sections (1 mm or less) are important to provide adequate spatial resolution and
high-quality 3D reconstruction images.
Volumetric imaging permits multiplanar reconstruction of cross-sectional images to display
the coronary arteries. Curved multiplanar reconstruction and thin-slab maximum intensity
projections provide an overview of the coronary arteries, and volume-rendering techniques
provide a 3D anatomical display of the exterior of the heart. Two different CT technologies
can achieve high-speed CT imaging. Electron beam CT (EBCT, also known as ultrafast CT)
uses an electron gun rather than a standard x-ray tube to generate x-rays, thus permitting very
rapid scanning, on the order of 50–100 milliseconds per image. Helical CT scanning (also
referred to as spiral CT scanning) also creates images at greater speed than conventional CT
by continuously rotating a standard x-ray tube around the patient so that data are gathered in
a continuous spiral or helix rather than as individual slices. Helical CT is able to achieve scan
times of 500 milliseconds or less per image, and use of partial ring scanning or postprocessing algorithms may reduce the effective scan time even further.
Multidetector row helical CT (MDCT) or multislice CT scanning is a technologic evolution
of helical CT, which uses CT machines equipped with an array of multiple x-ray detectors
that can simultaneously image multiple sections of the patient during a rapid volumetric
image acquisition. MDCT machines currently in use have 64 or more detectors.
A variety of noninvasive tests are used in the diagnosis of coronary artery disease. They can
be broadly classified as those that detect functional or hemodynamic consequences of
obstruction and ischemia (exercise treadmill testing, myocardial perfusion imaging [MPI],
stress echo with or without contrast), and others identifying the anatomic obstruction itself
(cardiac CTA and coronary magnetic resonance imaging [MRI]). Functional testing involves
inducing ischemia by exercise or pharmacologic stress and detecting its consequences.
However, not all patients are candidates. For example, obesity or obstructive lung disease can
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make obtaining echocardiographic images of sufficient quality difficult. Conversely, the
presence of coronary calcifications can impede detecting coronary anatomy with cardiac
CTA. Accordingly, some tests will be unsuitable for particular patients.
Evaluation of obstructive coronary artery disease (CAD) involves quantifying arterial
stenoses to determine whether significant narrowing is present. Lesions with greater than
50% to 70% diameter stenosis accompanied by symptoms are generally considered
significant and often result in revascularization procedures. It has been suggested that cardiac
CTA may be helpful to rule out the presence of CAD and to avoid invasive coronary
angiography (ICA) in patients with a low clinical likelihood of significant CAD. Also of note
is the interest in the potential important role of non-obstructive plaques (i.e., those associated
with <50% stenosis) because their presence is associated with increased cardiac event rates.
Cardiac CTA can also visualize the presence and composition of these plaques and quantify
the plaque burden better than conventional angiography, which only visualizes the vascular
lumen. Plaque presence has been shown to have prognostic importance.
The information sought from angiography after coronary artery bypass graft surgery may
depend on the length of time since surgery. Bypass graft occlusion may occur during the
early postoperative period; whereas, over the long term, recurrence of obstructive CAD may
occur in the bypass graft, which requires a similar evaluation as CAD in native vessels.
Congenital coronary arterial anomalies (i.e., abnormal origination or course of a coronary
artery) that lead to clinically significant problems are relatively rare. Symptomatic
manifestations may include ischemia or syncope. Clinical presentation of anomalous
coronary arteries is difficult to distinguish from other more common causes of cardiac
disease; however, an anomalous coronary artery is an important diagnosis to exclude,
particularly in young patients who present with unexplained symptoms (e.g., syncope). There
is no specific clinical presentation to suggest a coronary artery anomaly.
Cardiac CTA has several important limitations. The presence of dense arterial calcification or
an intracoronary stent can produce significant beam-hardening artifacts and may preclude a
satisfactory study. The presence of an uncontrolled rapid heart rate or arrhythmia hinders the
ability to obtain diagnostically satisfactory images. Evaluation of the distal coronary arteries
is generally more difficult than visualization of the proximal and mid-segment coronary
arteries due to greater cardiac motion and the smaller caliber of coronary vessels in distal
locations.
Radiation delivered with current generation scanners utilizing reduction techniques
(prospective gating and spiral acquisition) has declined substantially—typically to under 10
mSv. For example, an international registry developed to monitor cardiac CTA radiation
recently reported a median 2.4 mSv (interquartile range, [IQR]: 1.3 to 5.5) exposure. In
comparison, radiation exposure accompanying rest-stress perfusion imaging ranges varies
according to isotope used—approximately 5 mSv for rubidium-82 (positron emission
tomography, PET), 9 mSv for sestamibi (single-photon emission computed tomography,
SPECT), 14 mSv for F-18 FDG (fludeoxyglucose) (PET), and 41 mSv for thallium; during
diagnostic invasive coronary angiography, approximately 7 mSv will be delivered. EBCT
using electrocardiogram (ECG) (EKG) triggering delivers the lowest dose (approximately 0.7
to 1.1 mSv with 3-mm sections). Any cancer risk due to radiation exposure from a single
cardiac imaging test depends on age (higher with younger age at exposure) and gender
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(greater for women). Empirical data suggest that every 10 mSv of exposure is associated with
a 3% increase in cancer incidence over 5 years.
The use of Computed Tomography to Detect Coronary Artery Calcification (Electron-beam
CT) is addressed in a separate policy.
POLICY
I. Provider Accreditation for CCTA – Network Providers
Effective 01/01/2013, all Network Providers billing the technical component of the CT
must be accredited in Coronary CTA by the Intersocietal Accreditation Commission
(IAC) or a Cardiac CT module by the American College of Radiology (ACR). The
professional component of the CT will be reimbursed based upon the accreditation of the
facility as the ACR and the IAC facility accreditations require that interpreting
professional physicians also be accredited by the ACR or Society of Cardiovascular
Computed Tomography, respectively.
II. Medically Necessary CCTA
A diagnosis of chest pain (acute or non-acute) is not in itself an eligible indication for
performing CCTA. CCTA using a 64-slice or greater CT scanner is considered
medically necessary for the following:
A. Detection of CAD in Symptomatic Patients
1. Evaluation of chest pain syndrome
 Intermediate pre-test probability of CAD (see Table A below)
and electrocardiogram (ECG) (EKG) uninterpretable or unable
to exercise
2. Evaluation of intra-cardiac structures
 Evaluation of suspected coronary anomalies
3. Acute chest pain
 Intermediate pre-test probability of CAD (see Table A below)
and no electrocardiogram (ECG) (EKG) changes and serial
enzymes negative
4. Abnormal electrocardiogram (ECG) (EKG)
 Left bundle branch block/left ventricle hypertrophy with ST
segment changes
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Table A. Pre-test Probability of CAD by Age, Gender and Symptoms
Age
Years
Gender
Typical/Definite
Angina Pectoris
Atypical/Probable
Angina Pectoris
Nonanginal
Chest Pain
Asymptomatic
30-39
Men
Intermediate
Intermediate
Low
Very Low
30-39
Women
Intermediate
Very Low
Very Low
Very Low
40-49
Men
High
Intermediate
Intermediate
Low
40-49
Women
Intermediate
Intermediate
Low
Very Low
50-59
Men
High
Intermediate
Intermediate
Low
50-59
Women
Intermediate
Intermediate
Low
Very Low
≥ 60
Men
High
Intermediate
Intermediate
Low
≥ 60
Women
High
Intermediate
Intermediate
Low
Typical angina (definite): 1) Substernal chest pain or discomfort is 2) provoked by exertion or emotional stress
and 3) relieved by rest and/or nitroglycerin.
Atypical angina (probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical
angina.
Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.
High: Greater than 90%
pre-test probability
Intermediate: Between 10%
and 90% pre-test probability
Low: Between 5% and
10% pre-test probability
Very Low: Less than
5% pre-test
probability
OR
Calculated Framingham Coronary Heart Disease Risk Score of >10 %
B. Detection of CAD with Prior Test Results
1. Evaluation of chest pain syndrome
 Un-interpretable or equivocal stress test (exercise, perfusion, or
stress echo)
 Conventional angiography is unsuccessful or equivocal
C. Evaluation of Acute Chest Pain in the Emergency Room/Emergency
Department
1. Evaluation of acute chest pain in the Emergency Room/Emergency
Department for patients with intermediate pre-test probability of CAD (see
Table A) that meet ALL of the following criteria:
 No known coronary artery disease;
 Normal or equivocal serum biomarkers including creatine kinasemyocardial band, myoglobin and/or troponin I;
 Normal or equivocal ischemic electrocardiogram (ECG) (EKG)
changes such as ST-segment elevation or depression ≥1mm in 2 or
more contiguous leads, and or T-wave inversion ≥2ml
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D. Evaluation of Cardiac Structure and Function
1. Morphology
a. Assessment of congenital heart disease including anomalies of
coronary circulation, great vessels, and cardiac chambers and valves
b. Evaluation of coronary arteries in patients with new onset heart failure
to assess etiology
2. Evaluation of intra- and extra-cardiac structures
a. Evaluation of cardiac mass (suspected tumor or thrombus) and patients
with technically limited images from echocardiogram, MRI or TEE
b. Evaluation of pericardial conditions (pericardial mass, constrictive
pericarditis, or complications of cardiac surgery) and patients with
technically limited images from echocardiogram, MRI or TEE
c. Evaluation of pulmonary vein anatomy prior to invasive
radiofrequency ablation for atrial fibrillation (e.g., pulmonary vein
isolation)
d. Non-invasive coronary vein mapping prior to placement of
biventricular pacemaker or, placement of automatic implantable
cardioverter defibrillator (AICD)
e. Non-invasive coronary arterial and venous bypass mapping, including
internal mammary artery and bypass grafts prior to repeat cardiac
vascularization
3. Evaluation of aortic and pulmonary disease
a. Evaluation of suspected aortic dissection or thoracic aortic aneurysm
b. Evaluation of suspected pulmonary embolism
III. Not Medical Necessary CCTA
The following are considered not medically necessary for CCTA :
 CCTA performed for screening purposes in asymptomatic patients (absence of
signs, symptoms, or disease)
 CCTA performed for low risk pre-test probability of CAD
o Patients with non anginal chest pain in whom the history, physical
exam, and appropriate diagnostic tests demonstrate non cardiac causes
of chest pain.
o Patients with low risk of coronary artery disease based on clinical
information and any other normal noninvasive coronary anatomic test
within the past six months
 CCTA performed for high risk pre-test probability of CAD
o Patients who meet the ACC/AHA Guidelines for Coronary
Angiography
o Patients with high pretest likelihood of coronary artery disease (by
age, gender, and symptoms) in whom coronary angiography is
indicated and or has been scheduled.
 CCTA services conducted by Network Providers who do not meet the
requirements outlined in the Provider Accreditation section above.
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IV. Relative Contraindications to CCTA
The following are relative contraindications to CCTA:
 Irregular rhythm (e.g., atrial flutter, frequent irregular premature ventricular
contractions or premature atrial contractions, and high grade heart block).
 Very obese patients, body mass index > 40 kg/m2.
 Renal insufficiency, creatinine > 1.8 mg/dl.
 Heart rate > 70 beats/minute refractory to heart-rate lowering agents (e.g., a
combination of beta-blocker and calcium-channel blocker)
 Calcium score > 1,000
 Previous stents < 2.5 mm in diameter
POLICY EXCEPTIONS
State Health Plan (SHP) Members: The Provider Accreditation requirements do not apply
to SHP members. However, the medical necessity criteria outlined in the Policy section must
be met for SHP members.
Federal Employee Program (FEP) Members: The Provider Accreditation requirements do
not apply to FEP members. For FEP members, contrast-enhanced computed tomographic
angiography for evaluation of anomalous (native) coronary arteries in symptomatic patients
may be considered medically necessary when conventional angiography is unsuccessful or
equivocal and when the results will impact treatment. Also, contrast-enhanced computed
tomographic angiography for the evaluation of patients without known coronary artery
disease and acute chest pain in the emergency room/emergency department setting is
considered medically necessary.
POLICY GUIDELINES
Only one professional component and one technical component will be allowed for the
performance of CCTA.
Investigative service is defined as the use of any treatment procedure, facility, equipment,
drug, device, or supply not yet recognized by certifying boards and/or approving or licensing
agencies or published peer review criteria as standard, effective medical practice for the
treatment of the condition being treated and as such therefore is not considered medically
necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of
the Member's specific benefit plan language.
POLICY HISTORY
12/13/2012: New policy added. Effective 01/01/2013.
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SOURCE(S)
Cardiology Physician Advisory Committee
Blue Cross Blue Shield Association Policy # 6.01.43
Cardiac Computed Tomography (CCT), Cardiac Computed Tomography Angiography
(CCTA) medical policy, Blue Cross and Blue Shield of Alabama
Computed Tomography, Cardiac and Coronary Artery medical policy, Arkansas Blue Cross
and Blue Shield
Framingham Heart Study Coronary Heart Disease Risk Factors:
http://www.framinghamheartstudy.org/risk/coronary.html
Intersocietal Accreditation Commission (IAC) CT/ICACTL Standards and Guidelines for CT
Accreditation, August 2012.
CODE REFERENCE
Covered Codes
This is not intended to be a comprehensive list of codes. Some covered procedure codes
have multiple descriptions.
The code(s) listed below are ONLY covered if the procedure is performed according to
the "Policy" section of this document.
Code Number
Description
CPT-4
75572
Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology (including 3D
image postprocessing, assessment of cardiac function, and
evaluation of venous structures, if performed)
75573
Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology in the setting
of congenital heart disease (including 3D image
postprocessing, assessment of LV cardiac function, RV
structure and function and evaluation of venous structures, if
performed)
75574
Computed tomographic angiography, heart, coronary arteries
and bypass grafts (when present), with contrast material,
including 3D image postprocessing (including evaluation of
cardiac structure and morphology, assessment of cardiac
function, and evaluation of venous structures, if performed)
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ICD-9 Procedure
ICD-9 Diagnosis
164.1
Malignant neoplasm of heart
212.7
Benign neoplasm of heart
394.0 – 394.9
Diseases of mitral valve
396.0 – 396.9
Diseases of mitral valve and aortic valves
397.0 – 397.9
Diseases of other endocardial structures
411.1
Intermediate coronary syndrome
411.81
Acute coronary occlusion without myocardial infarction
411.89
Other acute and subacute form of ischemic heart disease
413.0 – 413.9
Angina pectoris code range
414.01
Coronary atherosclerosis of native coronary artery
414.02
Coronary atherosclerosis of autologous vein bypass graft
414.03
Coronary atherosclerosis of nonautologous biological bypass
graft
414.04
Coronary atherosclerosis of artery bypass graft
414.05
Coronary atherosclerosis of unspecified type of bypass graft
414.10 – 414.19
Aneurysm and dissection of heart code range
414.2
Chronic total occlusion of coronary artery
414.3
Coronary atherosclerosis due to lipid rich plaque
414.4
Coronary atherosclerosis due to calcified coronary lesion
414.8
Other specified forms of chronic ischemic heart disease
414.9
Chronic ischemic heart disease, unspecified
415.0 – 415.19
Acute pulmonary heart disease code range
416.0 – 416.9
Chronic pulmonary heart disease code range
420.0
Acute pericarditis in diseases classified elsewhere
420.90 – 420.99
Other and unspecified acute pericarditis code range
421.9
Acute endocarditis, unspecified
422.90
Acute myocarditis, unspecified
423.0 – 423.9
Other diseases of pericardium code range
424.0
Mitral valve disorders
424.1
Aortic valve disorders
424.3
Pulmonary valve disorders
424.90
Endocarditis, valve unspecified
425.0
Endomyocardial fibrosis
425.4
Other primary cardiomyopathies
426.3
Left bundle branch block
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427.31
Atrial fibrillation
428.0
Congestive heart failure, unspecified
428.1
Left heart failure
428.20 – 428.23
Systolic heart failure
428.30 – 428.33
Diastolic heart failure
428.40 – 428.43
Combined systolic and diastolic heart failure
429.0
Myocarditis, unspecified
429.1
Myocardial degeneration
429.3
Cardiomegaly
429.4
Functional disturbances following cardiac surgery
441.0 – 441.03
Dissection of aorta code range
441.1
Thoracic aneurysm, ruptured
441.2
Thoracic aneurysm without mention of rupture
441.6
Thoracoabdominal aneurysm, ruptured
441.7
Thoracoabdominal aneurysm, without mention of rupture
447.70 – 447.73
Aortic ectasia
745.0
Common truncus
745.10 – 745.19
Transposition of great vessels
745.2
Tetralogy of Fallot
745.3
Common ventricle
745.4
Ventricular septal defect
745.5
Ostium secundum type atrial septal defect
745.60 – 745.69
Endocardial cushion defects
745.7
Cor biloculare
745.8
Other bulbus cordis anomalies and anomalies of cardiac septal
closure.
745.9
Unspecified defect of septal closure
746.00 – 746.09
Anomalies of pulmonary valve
746.1 – 746.7
Other congenital anomalies of heart
746.81 – 746.89
Other specified anomalies of heart
747.0
Patent ductus Botalli
747.10 – 747.11
Coarctation of aorta code range
747.20 – 747.29
Other anomalies of aorta code range
747.31 – 747.39
Anomalies of pulmonary artery code range
747.41
Total anomalous pulmonary venous connection
747.42
Partial anomalous pulmonary venous connection
747.49
Other congenital anomalies of great veins
786.51
Precordial pain
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794.31
Abnormal electrocardiogram [ECG] [EKG]
997.1
Cardiac complications
V45.81
Aortocoronary bypass status
V72.81
Preoperative cardiovascular examination
HCPCS
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