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Medical Policy: 06.01.06
Original Effective Date: September 2000
Reviewed: November 2011
Revised: December 2006
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:
Quantitative coronary artery calcium scoring may be used as a screening test for detecting individuals who may be at risk for developing coronary artery disease. This test may be performed using electron beam computed tomography (EBCT) or multislice computed tomography scanners dedicated to cardiac imaging.
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Prior Approval:
Not applicable
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Policy:
Quantitative coronary artery calcium scoring, either by electron beam computed tomography or multislice computed tomography scanner is considered investigational.
There is lack of high-quality evidence assessing the impact of this testing on cardiovascular outcomes.
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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 diagnostic codes.
- Providers may use the HCPCS code S8092 to report EBCT services.
- 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
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Selected References:
- Agatston, A.S., Janowitz, W.R., Holdner, F.J., et al. Quantification of coronary artery calcium using ultrafast computed tomography. Journal of the American College of Cardiology. 2000; 15:827-32.
- Arad, Y., Spadaro, L.A., Goodman, K., et al. Predictive value of electron beam computed tomography of the coronary arteries. 19 month follow-up of 1173 asymptomatic subjects. Circulation. 1996; 93(11):1951-3.
- Blue Cross and Blue Shield Association. Electron beam computed tomography. Technology Evaluation Center Assessments. 1994; 9(16):1-15.
- Budoff, M.J., Georgiou, D., Brody, A., et al. Ultrafast computed tomography as a diagnostic modality in the detection of coronary artery disease. Circulation. 1996; 93:898-904.
- Detrano, R.C. Coronary artery scanning using electron beam computed tomography. American Journal of Cardiac Imaging. 1996; 10(2):97-100.
- Secci, A., Wong, N., Tang, W., et al. Electron beam computed tomographic coronary calcium as a predictor of coronary events: comparison of two protocols. Circulation. 1997; 96(4):1122-9.
- Teng, W., Wong, N.D., Abrahamson, D., et al. Relation of electron beam computed tomography screening for coronary calcium to cardiovascular risk and disease: a review. Coronary Artery Disease. 1996; 7:383-9.
- Thompson, G.R., Forbat, S., Underwood, R. Electron-beam CT scanning for detection of coronary calcification and prediction of coronary heart disease. QJM. 1996; 89(8):565-70.
- Wexler, L., Brundage, B., Crouse, J., et al. Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications. A statement for health professionals from the American Heart Association Writing Group. Circulation. 1996; 94(5):1175-97.
- Wong, N.D., Detrano, R.C., Diamond, G., et al. Does coronary artery screening by electron beam computed tomography motivate potentially beneficial lifestyle behaviors? American Journal of Cardiology. 1996; 78:1220-3.
- O'Malley PG, Feurstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavioral change, and cardiovascular risk profile: a randomized controlled trial. JAMA. 2003 May 7;289(17):2215-23.
- Greenland P, Gaziano JM. Selecting Asymptomatic Patients for Coronary Computed Tomography for Electrocardiographic Exercise Testing. N Engl J Med 2003, Jul. 239;5.
- Tiechholz LE, Petrillo S, Larson AJ, Klig V. Quantitative assessment of atherosclerosis by electron beam tomography. Am J Cardiol. 2002 Dec 15;90(12):1416-9.
- Raggi P, Callister TQ, Cooil B, Russo DJ, Lippolis NJ, Patterson RE. Evaluation of chest pain in patients with low to intermediate pretest probability of coronary artery disease by electron beam computed tomography. Am J Cardiol. 2000 Feb. 1:85(3):283-8.
- ECRI. Computed Tomography for Predicting Coronary Artery Disease Risk. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 2004 Apr. 39 p. (Windows on medical technology; no. 107).
- Almeda FQ, Shah R, Senter S et al. Clinical and angiographic profile of patients with markedly elevated coronary calcium scores (>/=1000) detected by electron beam computed tomography. Cardiovasc Radiat Med. 2004 Jul-Sep; 5(3):109-12.
- Ratliff NB 3rd, Jorgensen CR, Gobel et al. Lack of usefulness of electron beam computed tomography for detecting coronary allograft vasculopathy. Am J Cardiol. 2004 Jul 15; 94(2):2002-6.
- ECRI. Computed Tomography for Cardiovascular Disease Screening. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2006 Nov. (Health Technology Forecast).
- Budoff MJ, Achenbach S, Blumenthal RS et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006 Oct 17;114(16):1761-91.
- Greenland P, Bonow RO, Brundage BH, Budoff MJ, American College of Cardiology Foundation Clinical Expert . Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography); Society ofAtherosclerosis Imaging and Prevention; Society of Cardiovascular ComputedTomography.Circulation. 2007 Jan 23;115(3):402-26. Epub 2007 Jan 12.
- Michos ED, Vasamreddy CR, Becker DM, Yanek LR, Moy TF, Fishman EK, Becker LC,Blumenthal RS. Women with a low Framingham risk score and a family history of premature coronary heart disease have a high prevalence of subclinical coronary atherosclerosis. Am Heart J. 2005 Dec;150(6):1276-81.
- Polonsky TS, McClelland RL, Jorgensen NW et al. Coronary Artery Calcium Score and Risk Classification for Coronary Heart Disease Prediction. JAMA. Apr 28, 2010; 303(16):1610-16.
- ECRI. Calcium scoring may be useful screening for chest pain in emergency departments. Plymout Meeting (PA): ECRI Health Technology Information Service; 2010 February 12. (Health Technology Forecast).
- Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Preventive Services for Adults. 17th edition. September 2011. Accessed November 2011.
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Policy History:
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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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.
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