Cardiac Computed Tomographic Angiography (CCTA)

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 Page 1 of 10

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 Page 2 of 10

(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 Page 3 of 10

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 OR Low: Between 5% and 10% pre-test probability Very Low: Less than 5% pre-test probability 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 Page 4 of 10

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. Page 5 of 10

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. Page 6 of 10

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) Page 7 of 10

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 Page 8 of 10

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 Page 9 of 10

794.31 Abnormal electrocardiogram [ECG] [EKG] 997.1 Cardiac complications V45.81 Aortocoronary bypass status V72.81 Preoperative cardiovascular examination HCPCS Top Page 10 of 10