Medical Policy: 06.01.06
Original Effective Date: September 2000
Reviewed: July 2017
Revised: July 2017
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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.
Coronary artery calcium (CAC) scoring is a noninvasive test that has been reported to detect the presence of coronary artery disease (CAD) by measuring the location and extent of calcium in the coronary arteries. The use of CAC scores has been studied in the prediction of future risk of CAD in asymptomatic patients and in the diagnosis of CAD in symptomatic patients.
The most widely studied indication is for the use of CAC in the prediction of future risk for CAD in patients with subclinical disease, with the goal of instituting appropriate risk reducing therapy (e.g. statin therapy, lifestyle modifications) to improve outcomes. In addition, CAC has been evaluated in patients with symptoms potentially consistent with CAD, but in whom a diagnosis is unclear.
Electron beam computed tomography (ECBT; also known as ultrafast CT) and spiral CT (or helical CT) may be used as an alternative to conventional CT scanning due to their faster throughput. Their speed of image acquisition gives them unique value for imaging of the moving heart. The rapid image acquisition time virtually eliminates motion artifact related to cardiac contraction, permitting visualization of the calcium in the epicardial coronary arteries. ECBT software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting CAD, both as a diagnostic technique in symptomatic patients to rule out an atherosclerotic etiology of symptoms or, in asymptomatic patients, as an adjunctive method for risk stratification for CAD.
EBCT and multi-detector computed tomography were initially the primary fast CT methods for measurement of CAC. A fast CT study for CAC measurement generally takes 10 to 15 minutes and requires only a few seconds of scanning time. However, computed tomography angiography (CTA) has been used to assess coronary calcium. Because of the basic similarity between EBCT and CTA in measuring coronary calcium, it is expected that CTA provides information on coronary calcium that is similar to EBCT. Computed tomography (CT) scan derived coronary calcium measures have been used to evaluate coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not be causing ischemia or symptoms. Most clinical studies have examined the use of coronary calcium for its potential use in estimating the risk of future coronary heart disease (CAD) events.
Coronary calcium levels can be expressed in many ways. The most widely used is the Agatston score, which is a weighted summed total of calcified coronary artery area observed on computed tomography. This value can be expressed as an absolute number, commonly ranging from 0 to 400. These values can be translated into age and sex-specific percentile values.
- 0 – no identifiable disease
- 1 to 99 – mild disease
- 100 to 399 – moderate disease
- ≥ 400 – severe disease
Despite the potential benefits of coronary artery calcium screening, it is also subject to a number of limitations and therefore, there is disagreement on its value:
- Among asymptomatic patients with low Framingham risk score ( ≤ 5%), only a small number (less than 15%) of those with coronary artery calcification will have a cardiac event over the ensuing five years. Coronary artery calcification screening is unlikely to benefit low-risk or high-risk patients, and is not recommended.
- It has not been established that instituting or intensifying pharmacologic risk factor modification in asymptomatic patients with coronary artery calcification improves outcomes.
- The potential harm associated with false positives tests and radiation dose (especially with repeated testing) is not known.
- Providing patients with the results of coronary artery calcification testing may improve patient compliance with lifestyle changes and medications but results have been mixed.
- Cost effectiveness of coronary artery calcification screening has not been defined
For individuals who are asymptomatic with risk of coronary artery disease (CAD) who receive coronary artery calcium (CAC) scoring, the evidence includes multiple prospective studies. There is extensive evidence on the predictive value of CAC score screening for cardiovascular disease among asymptomatic patients, and this evidence has demonstrated that scanning has incremental predictive accuracy above traditional risk factor measurement. However, the evidence from high-quality studies that has demonstrated that the use of CAC score measurement in clinical practice leads to changes in patient management or in individual risk behaviors that improve cardiac outcomes is lacking. At least 1 randomized controlled trial (RCT) has suggested that the use of CAC score measurement in clinical practice may be associated with improved cardiac risk profiles, but an association between CAC score measurement with improved outcomes has not yet been demonstrated in other studies. The evidence is insufficient to determine the effects of the technology on net health outcomes.
For individuals with signs and/or symptoms suggested of CAD who receive CAC scoring before other diagnostic testing, the evidence includes prospective and retrospective nonrandomized studies. CAC scoring has potential as a diagnostic test to rule out CAD in patients presenting with symptoms or as a “gatekeeper” test before invasive imaging is performed. Evidence from retrospective studies has suggested that negative results on CAC scoring rule out CAD with good reliability, and at least 1 prospective study has suggested that CAC score can be used in an emergency setting to stratify patients for further testing. However, further prospective trials would be needed to demonstrate that such strategy is effective in practice and is at least as effective as alternative strategies for ruling out CAD. To demonstrate that use of calcium scores improves the efficiency or accuracy of the diagnostic workup of symptomatic patients, further studies that define exactly how CAC scores are used in combination with other tests in the triage of patient would be necessary. The evidence is insufficient to determine the effects of technology on net health outcomes.
Practice Guidelines and Position Statements
U.S. Preventive Services Task Force (USPSTF)
In 2009 the U.S. Preventative Services Task Force issued a recommendation regarding using non-traditional risk factors in coronary heart disease risk assessment, current evidence is insufficient to assess the balance of benefits and harms of using the non-traditional risk factors discussed in this statement to screen asymptomatic men and women with no history of CHD to prevent CHD events.
The non-traditional risk factors included in this recommendation are high sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness (carotid IMT), coronary artery calcification (CAC) score on electron beam computed tomography (EBCT), homocysteine level, and lipoprotein(a) level.
American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA):
2010 practice guideline by American College of Cardiology Foundation and the American Heart Association, for assessment of cardiovascular risk in asymptomatic adults: Computed Tomography for Coronary Calcium Scoring:
- Class IIa recommendation: Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10 year risk). (Level of Evidence: B)
- Class IIb recommendation: Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low to intermediate risk (6% to 10% 10 year risk). (Level of Evidence: B)
- Class III recommendation: No Benefit. Persons as low risk (<6% 10 year risk) should not undergo CAC measurement for cardiovascular risk assessment. (Level of Evidence: B)
In 2012, the American College of Cardiology (ACC)/ American Heart Association (AHA) released guidelines for the diagnosis and management of patients with stable ischemic heart disease that include some recommendations related to CAC scoring.
- Class IIb recommendation: For patients with low to intermediate pretest probability of obstructive IHD, non-contrast cardiac computed tomography to determine the coronary artery calcium score may be considered. (Level of Evidence: C)
In 2014, ACC/AHA issued focused update to the 2012 guideline on the diagnosis and management of patients with stable ischemic heart disease with no additional recommendations related to CAC scoring.
In 2013, the American College of Cardiology (ACA)/American Heart Association (AHA) released guidelines for the assessment of cardiovascular risk:
- Use of Newer Risk Markers After Quantitative Risk Assessment: If, after quantitative risk assessment, a risk based treatment decision is uncertain, assessment or 1 or more of the following: family history, hs-CRP, coronary artery calcification (CAC) score, or ABI may be considered to inform treatment decision making. (Level of Evidence B)
Coronary artery calcium scoring by means of computed tomography is considered investigational for all indications.
Based on the peer reviewed medical literature because of the lack of high-quality evidence demonstrating improved clinical outcomes or impact to treatment management from the use of coronary artery calcium (CAC) score either as screening tests to risk stratify patients or as a diagnostic test in symptomatic patients the use of coronary artery calcium scoring by means of computed tomography is considered investigational.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)
- 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
- 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.
- Ferket BS, Genders TS, Colkesen EB et al. Systematic review of guidelines on imaging of asymptomatic coronary artery disease. J Am Coll Cardiol. 2011 Apr 12;57(15):1591-600.
- Rana JS, Gransar H, Wong ND et al. Comparative value of coronary artery calcium and multiple blood biomarkers for prognostication of cardiovascular events. Am J Cardiol. 2012 May 15;109(10):1449-53. Epub 2012 Mar 16.
- Sniderman AD, Thanassoulis G, lawler PR et al. Comparison of coronary calcium screening versus broad statin therapy for patients at intermediate cardiovascular risk. Am J Cardiol. 2012 May 9. [Epub ahead of print].
- Jacobs PC, Gondrie MJ, can der Graaf Y et al. Coronary artery calium can predict all-cause mortality and cardiovascular events on low-dose CT screening for lung cancer. AJR Am J Roentgenol. 2012 Mar;198(3):505-11.
- Okwuosa TM, Greenland P, Burke GL et al. Prediction of coronary artery calcium progression in individuals with low Framingham Risk Score: the Multi-Ethnic Study of Atherosclerosis. JACC Cardiovasc Imaging. 2012 Feb;5(2):144-53.
- U.S. Preventative Services Task Force October 2009. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment, Recommendation Statement.
- 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. Circulation 2010; 122:e636.
- 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Journal of the American Cardiology j.jacc.2015.11.005.
- UpToDate. Screening for Coronary Heart Disease. Frank G. Yanowitz, M.D.. Topic last updated October 22, 2012.
- UpToDate. Diagnostic and Prognostic Implications of Coronary Artery Calcification Detected by Computed Tomography. Thomas C. Garber, M.D., PhD, FACC, FAHA, Christopher M. Kramer, M.D., FACC, FAHA. Topic last updated November 25, 2014.
- Nishant R. Shah, M.D., Stephanie A. Coulter, M.D., An Evidence Based Guideline for Coronary Calcium Scoring in Asymptomatic Patients Without Coronary Heart Disease, Vol 39, Number 2, 2012.
- Raimund Erbel, et al. Progression of Coronary Artery Calcification Seems to be Inevitable, but Predictable – Results of The Heinze Nixdorf Recall (HNR) Study. European Heart Journal. doi:10.1093/curheartj/ehu288
- Update. Screening for Coronary Heart Disease in Patients with Diabetes Mellitus. Jeroen J Bax, M.D., PhD, Frans J TH Wackers, M.D., PhD, Victoria Delgado M.D., PhD. Topic last updated April 29, 2016.
- Budoff MJ, Mohlenkamp S, McClelland R, et al. A comparison of outcomes with coronary artery calcium scanning in unselected populations: the Multi-Ethnic Study of Atherosclerosis (MESA) and Heinz Nixdorf RECALL study (HNR). J Cardiovasc Comput Tomogr. May-Jun 2013;7(3):182-191. PMID 23849491
- Martin SS, Blaha MJ, Blankstein R, et al. Dyslipidemia, coronary artery calcium, and incident atherosclerotic cardiovascular disease: implications for statin therapy from the multi-ethnic study of atherosclerosis. Circulation. Jan 7 2014;129(1):77-86. PMID 24141324
- Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. May 2014;7(3):453-460. PMID 24803472
- Silverman MG, Blaha MJ, Krumholz HM, et al. Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: the Multi-Ethnic Study of Atherosclerosis. Eur Heart J. Sep 1 2014;35(33):2232-2241. PMID 24366919
- Gibson AO, Blaha MJ, Arnan MK, et al. Coronary artery calcium and incident cerebrovascular events in an asymptomatic cohort. The MESA Study. JACC Cardiovasc Imaging. Nov 2014;7(11):1108-1115. PMID 25459592
- Chang SM, Nabi F, Xu J, et al. Value of CACS compared with ETT and myocardial perfusion imaging for predicting long-term cardiac outcome in asymptomatic and symptomatic patients at low risk for coronary disease: clinical implications in a multimodality imaging world. JACC Cardiovasc Imaging. Feb 2015;8(2):134-144. PMID 25677886
- Hou ZH, Lu B, Gao Y, et al. Prognostic value of coronary CT angiography and calcium score for major adverse cardiac events in outpatients. JACC Cardiovasc Imaging. Oct 2012;5(10):990-999. PMID 23058065
- Meyer M, Henzler T, Fink C, et al. Impact of coronary calcium score on the prevalence of coronary artery stenosis on dual source CT coronary angiography in Caucasian patients with an intermediate risk. Acad Radiol. Nov 2012;19(11):1316-1323. PMID 22897947
- Petretta M, Daniele S, Acampa W, et al. Prognostic value of coronary artery calcium score and coronary CT angiography in patients with intermediate risk of coronary artery disease. Int J Cardiovasc Imaging. Aug 2012;28(6):1547-1556. PMID 21922205
- Whelton SP, Nasir K, Blaha MJ, et al. Coronary artery calcium and primary prevention risk assessment: what is the evidence? An updated meta-analysis on patient and physician behavior. Circ Cardiovasc Qual Outcomes. Jul 1 2012;5(4):601-607. PMID 22811506
- Mamudu HM, Paul TK, Veeranki SP, et al. The effects of coronary artery calcium screening on behavioral modification, risk perception, and medication adherence among asymptomatic adults: a systematic review. Atherosclerosis. Oct 2014;236(2):338-350. PMID 25128971
- Johnson JE, Gulanick M, Penckofer S, et al. Does Knowledge of Coronary Artery Calcium Affect Cardiovascular Risk Perception, Likelihood of Taking Action, and Health-Promoting Behavior Change? J Cardiovasc Nurs. Jan 14 2014. PMID 24434820
- Shreibati JB, Baker LC, McConnell MV, et al. Outcomes after coronary artery calcium and other cardiovascular biomarker testing among asymptomatic medicare beneficiaries. Circ Cardiovasc Imaging. Jul 2014;7(4):655-662. PMID 24777939
- Yerramasu A, Lahiri A, Venuraju S, et al. Diagnostic role of coronary calcium scoring in the rapid access chest pain clinic: prospective evaluation of NICE guidance. Eur Heart J Cardiovasc Imaging. Feb 9 2014. PMID 24513880
- Pursnani A, Chou ET, Zakroysky P, et al. Use of coronary artery calcium scanning beyond coronary computed tomographic angiography in the emergency department evaluation for acute chest pain: the ROMICAT II trial. Circ Cardiovasc Imaging. Mar 2015;8(3). PMID 25710925
- Hulten E, Bittencourt MS, Ghoshhajra B, et al. Incremental prognostic value of coronary artery calcium score versus CT angiography among symptomatic patients without known coronary artery disease. Atherosclerosis. Mar 2014;233(1):190-195. PMID 24529143
- Chaikriangkrai K, Velankar P, Schutt R, et al. Additive prognostic value of coronary artery calcium score over coronary computed tomographic angiography stenosis assessment in symptomatic patients without known coronary artery disease. Am J Cardiol. Mar 15 2015;115(6):738-744. PMID 25604930
- Fihn S, Blankenship J, Alexander K, et al. ACC/AHA/AATS/PCNA/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2014;64(18):1929-1949.
- Pursani A, Massaro JM, D’Agostino RB Sr, et. al. Guideline-based statin eligibility, coronary artery calcification and cardiovascular events, JAMA 2015 Jul 14;314(2):134-41. PMID 26172893
- Blaha MJ, Cainzos-Achirica M, Greenland P, et. al. Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: The multi-ethnic study of atherosclerosis (MESA). Circulation 2016 Mar 1:133(9):849-58. PMID 26801055
- Johnson JE, Gulanick M, Penckofer S, et. al. Dose knowledge of coronary artery calcium effect cardiovascular risk perception, likelihood of taking action, and health-promoting behavior change? J Cardiovasc Nurs 2015 Jan-Feb:30(1):15-25. PMID 24434820
- Korley FK, George RT, Jaffe AS, et. al. Low high-sensitivity troponin I and zero coronary artery calcium score identifies coronary CT angiography candidates in whom further testing could be avoided. Acad Radiol 2015 Aug;22(8):1060-7. PMID 26049777
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