Computed Tomography (CT) and Computed Tomography Angiography (CTA) for Coronary Artery Evaluation Printer-Friendly Version   

Medical Policy: 06.01.20 
Original Effective Date: October 2005 
Reviewed: March 2008 
Revised: March 2007 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

Policy: 

Cardiac computed tomography (CT) may be considered medically necessary for the following indications:

• Evaluation of intra- and extra-cardiac structures in patients with:
  • Suspected cardiac mass (i.e., tumor or thrombus)
  • Technically limited images from echocardiograms, MRI, or TEE
  • Pericardial conditions (i.e., pericardial mass, constrictive pericarditis, or complications of cardiac surgery)
  • Atrial fibrillation who are being considered for invasive radiofrequency ablation to evaluate pulmonary vein anatomy; OR                                                      
  • Non-invasive coronary vein mapping prior to placement of a biventricular pacemaker
  • Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization

Computed tomography angiography (CTA) may be considered medically necessary to evaluate the coronary arteries for the following indications:

• Evaluation of acute chest pain in patients with:
  • Intermediate pre-test probability of coronary artery disease
  • No EKG changes
  • Serial enzymes negative
• Evaluation of chest pain syndrome in patients with:
  • Intermediate probability of coronary artery disease
  • EKG uninterpretable or;
  • Patient unable to exercise; OR
  • Prior uninterpretable or equivocal stress test (exercise, perfusion or stress echo) who require further evaluation
• Evaluation of intracardiac structures in patients with:
  • Suspected coronary anomalies
• 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:
  • Suspected aortic dissection or thoracic aortic aneurysm
  • Suspected pulmonary embolism

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
  • High pre-test probability of coronary artery disease
  • EKG-ST-segment elevation and/or
  • Positive cardiac enzymes
• Evaluation of acute chest pain in patients with:
  • Low pre-test probability of coronary heart disease
  • No EKG changes
  • Negative serial enzymes
• Detection of coronary artery disease in asymptomatic patients
• Risk assessment of asymptomatic patients with prior test results when:
  • There is high risk of coronary heart disease (based on Framingham criteria)
  • No significant obstructive disease was evident on cardiac CTA or invasive angiogram performed within the previous 2 years
• 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:
  • In patients following myocardial infarction
  • In patients with heart failure
• Characterization of native and prosthetic cardiac valves

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Procedure Codes and Billing Guidelines: 

• Use CPT 0145T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology 
• Use CPT 0146T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium 
• Use CPT 0147T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium 
• Use CPT 0148T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium 
• Use CPT 0149T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium 
• Use CPT 0150T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology in congenital heart disease 
• Use CPT 0151T Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing, function evaluation (left and right ventricular function, ejection-fraction and segmental wall motion) (List separately in addition to code for primary procedure)  

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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. 

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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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