|
Medical Policy: 06.01.20
Original Effective Date: October 2005
Reviewed: September 2011
Revised: March 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Computed tomography (CT) combines multiple x-ray images with the assistance of a computer to produce cross-sectional views of the body. Cardiac CT is a heart-specific imaging technology with or without contrast used to visualize heart anatomy, coronary circulation, and great vessels.
Computed tomography angiography (CTA) is the use of computed tomography scanners and injected contrast agents to obtain images of blood vessels and diagnose existing coronary artery disease (CAD). Multislice or multidetector scanners (MSCT) rotate faster than early electron beam computed tomography scanners and have 64-slice, and greater, image capability per rotation, resulting in increased speed and improved spatial and temporal high-resolution images.
The image quality of multislice scans is improved when the patient’s heart rate is less than sixty-five beats per minute. To achieve a heart rate less than sixty-five beats per minute current clinical practice is to medicate the patient with an oral or intravenous beta blocker. Calcium channel blockers may be used if the patient has a contraindication to beta blockers. Patient exposure to radiation is a concern with multi-slice computed tomography, which administers approximately twice the radiation dose of invasive coronary angiography. However, the relative risk of mortality with MSCT is approximately half that of invasive coronary angiography.
 Top
Prior Approval:
Not applicable
Top
Policy:
Cardiac computed tomography (CT) may be considered medically necessary for any of the following indications:
Computed tomography angiography (CTA) may be considered medically necessary to evaluate the coronary arteries for any of the following indications:
-
Evaluation of acute chest pain in patients with:
-
Evaluation of chest pain syndrome in patients with:
-
Intermediate probability of coronary artery disease
-
EKG uninterpretable
-
Patient unable to exercise
-
Prior uninterpretable or equivocal stress test (exercise, perfusion or stress echo) who require further evaluation
-
Evaluation of intracardiac structures in patients with:
-
Evaluation of cardiac structure and morphology to:
-
Assess complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves
-
Evaluate coronary arteries in patients with new onset heart failure to assess etiology
-
Evaluate coronary arteries prior to non-coronary cardiac surgery
-
Evaluation of aortic and pulmonary disease in patients with:
Based upon appropriateness criteria from a multidisciplinary cardiac CTA and cardiac MRI work group, computed tomographic angiography is considered investigational for all other indications including:
-
Evaluation of chest pain in patients with:
-
High pre-test probability of coronary artery disease or;
-
Evidence of moderate to severe ischemia on stress test (i.e., exercise, perfusion, or stress echo); or
-
Intermediate pre-test probability of coronary heart disease with an interpretable EKG and are able to exercise
-
Evaluation of acute chest pain in patients with
-
Evaluation of acute chest pain in patients with:
-
Detection of coronary artery disease in asymptomatic patients
-
Risk assessment of asymptomatic patients with prior test results when:
-
Preoperative evaluation for non-cardiac surgery
-
Post-revascularization evaluation of bypass grafts and coronary anatomy after CABG
-
Post-revascularization for in-stent restenosis after percutaneous coronary intervention (PCI)
-
Evaluation of left ventricular (LV) function:
-
Characterization of native and prosthetic cardiac valves
Top
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS) level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 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)
Top
Selected References:
- Leber AW, Knez A, Becker C et al. Non-invasive intravenous coronary angiography using electron beam tomography and multi-slice computed tomography. Heart. 2003; 89(6):633-9.
- Achenbach S, Ropers D, Regenfus M et al. Noninvasive coronary angiography by magnetic resonance imaging, electron-beam computed tomography, and multi-slice computed tomography. Am J Cardiol. 2001; 88(2A):70E-73E.
- Mollet NR, Cademartiri, F, Nieman K et al. Multislice spiral computed tomography coronary angiography in patients with stable angina pectoris. J Am Coll Cardiol. 2004; 43(12):2265-70.
- Maruyama T, Yoshizumi T, Tamura R et al. Comparison of visibility and diagnostic capability of noninvasive coronary angiography by eight-slice multidetector-row computed tomography versus conventional coronary angiography. Am J Cardiol. 2004; 93(5):537-42.
- Raff GL, Gallagher MJ, O'Neill WW, Goldstein JA. Diagnostic Accuracy of Noninvasive Coronary Angiography Using 64-Slice Sprial Computed Tomography. J Am Coll Cardiol. 2005; 46(3)552-7.
- Hoffman MHK, Heshui S, Schmitz BL et al. Noninvasive Coronary Angiography With Multislice Computed Tomography. JAMA. 2005; 293(20):2471-8.
- Blue Cross and Blue Shield Association. Contrast-Enhanced Cardiac Computed Tomographic Angiography for Coronary Artery Evaluation. Technology Evaluation Center. Assessment Program 2005; 20(4).
- Schoenhagen P, Stillman A, Garcia M et al. Coronary artery imaging with multidetector computed tomography: A call for an evidence-based, multidisciplinary approach. Am Heart J 2006 May; 151(5):945-8.
- Fine JJ, Hopkins CB, Ruff N et al. Comparison of Accuracy of 64-slice Cardiovascular Computed Tomography with Coronary Angiography in Patients with Suspected Coronary Artery Disease. Am J Cardiol 2006 Jan; 97(2):173-4.
- Ropers D, Rixe J, Anders K et al. Usefulness of Multidetector Row Spiral Computed Tomography With 64- × 0.6-mm Collimation and 330-ms Rotation for the Noninvasive Detection of Significant Coronary Artery Stenoses. Am J Cardiol 2006 Feb; 97(3):343-348.
- Mollet NR, Cademartiri F, van Mieghem CAG et al. High-Resolution Spiral Computed Tomography Coronary Angiography in Patients referred for Diagnostic Conventional Coronary Angiography. Circulation. 2005; 112:2318-2323.
- Leschka S, Alkadhi H, Plass A et al. Accuracy of MSCT coronary angiography with 64-slice technology: a first experience. Eur Heart J. Aug 2005; 26(15):1451-3.
- Stein PD, Beemath A Kayali F et al. Multidetector Computed Tomography for the Diagnosis of Coronary Artery Disease: A Systematic Review. Am J Med. 2006 Mar; 119(3):203-16.
- Agency for Healthcare Research and Quality. Technology Assessment Program. Non-Invasive Imaging for Coronary Artery Disease. April 28, 2006.
- Blue Cross Blue Shield Association. Technology Evaluation Center. Contrast-Enhanced Cardiac Computed Tomographic Angiography in the Diagnosis of Coronary Artery Stenosis or for Evaluation of Acute Chest Pain. TEC Assessment Program 2006 Aug; 21(5).
- Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. J Am Coll Cardiol 2006 Oct; 48(7):1475-97.
- Jacobs JE, Boxt LM, Desjardins B et al. ACR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography. J Am Coll Radiol 2006;48(3):677-685.
- Jones CM, Athanasiou T, Dunne N et al. Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis. Ann Thorac Surg. 2007 Jan;83(1):341-8.
- Hamon M, Biondi-Zoccai GG, Malagutti P et al. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 2006;48(9):1896-910.
- Mark DB, Berman DS, Budoff MJ et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010;55:2663-99.
- Raff GL, Chinnaiyan KM, Share DM et al. Radiation dose from cardiac computed tomography before and after implementation of radiation dose-reduction techniques. JAMA. 2009;301:2340-8.
- Kim JW, Kang EY, Yong HS et al. Incidental extracardiac findings at cardiac CT angiography: comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan. Int J Cardiovasc Imaging. 2009;25 Suppl 1:75-81.
- Bamberg F, Sommer WH, Hoffmann V et al. Meta-analysis and systematic review of the long-term predictive value of assessment of coronary atherosclerosis by contrast-enhanced coronary computed tomography angiography. J Am Coll Cardiol 2011;57(24):2426-36.
Top
Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
