Computed Tomography Angiography for Coronary Artery Evaluation
DESCRIPTION
Computed tomography angiography (CTA) is a noninvasive procedure that obtains volumetric images of blood vessels by using intravenously administered contrast material and high-resolution, high-speed computed tomography (CT) technology. There are different types of CT technology that can achieve high-speed CT imaging:
Electron beam computed tomography (i.e., ultrafast CT, cine computed tomography, rapid acquisition x-ray computed tomography and high-speed computed x-ray tomography) uses a rotating electron gun rather than a standard x-ray tube.
Helical or spiral CT scanning can also capture images at a higher speed than conventional CT by continuously rotating a standard x-ray tube around an individual in a continuous spiral, rather than individual slices.
Multi-slice spiral computed tomography (MSCT) and multidetector row computed tomography (MDCT) a technical evolution of helical CT that takes multiple, thin slices simultaneously, using CT machines equipped with an array of multiple x-ray detectors imaging multiple sections of the individual during a rapid volumetric image acquisition.
Coronary tomography angiography has been proposed as a noninvasive alternative to invasive coronary angiography. Potential applications of CT angiography include evaluation of coronary artery disease, coronary artery bypass graft patency, coronary artery aneurysm, and congenital coronary artery anomaly.
POLICY
Contrast-enhanced computed tomographic angiography for the evaluation of anomalous coronary arteries is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Contrast-enhanced computed tomographic angiography for the evaluation of anomalous coronary arteries for asymptomatic individuals is considered not medically necessary.
Contrast-enhanced computed tomographic angiography for the evaluation of anomalous coronary arteries for other conditions/diseases, including, but not limited to, the following is considered investigational:
The first test in evaluating symptomatic individuals (e.g. chest pain)
Serial follow-up studies in symptomatic or asymptomatic individuals
For follow-up stent placement
To evaluate chest pain in an intermediate or high risk individual when a stress test is clearly positive or negative
Preoperative assessment for non-cardiac, nonvascular surgery
Preoperative imaging prior to robotic surgery (e.g. to visualize the entire aorta)
For determining plaque morphology or for quantification of coronary atherosclerotic plaque burden
Evaluation of left ventricular function following myocardial infarction or in chronic heart failure.
Myocardial perfusion and viability studies
Evaluation of individuals with postoperative native or prosthetic cardiac valves who have technically limited echocardiograms, MRI or TEE
Individuals with an indeterminate echocardiogram
See also: Computed Tomography to Detect Coronary Artery Calcification
MEDICAL APPROPRIATENESS
Contrast-enhanced computed tomographic angiography for the evaluation of anomalous coronary arteries is considered medically appropriate if ALL of the following criteria are met:
ANY ONE of the following criteria are met:
The individual with symptomatic pretest probability of coronary artery disease who can not perform or has contraindications to exercise and chemical stress testing
The individual with new onset heart failure
The individual with dilated cardiomyopathy with at least an intermediate coronary risk
The individual who has the need for an anomalous coronary artery mapped prior to an invasive procedure
The individual who has not had a previous imaging study but clearly demonstrates an anomalous coronary artery
The individual with dilated cardiomyopathy with at least intermediate coronary risk
The individual with patent anomalous artery and who are less than age 40 with a history that includes ANY ONE of the following:
Angina or myocardial infarction without high atherosclerosis risk
Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery
Resuscitated sudden death unexplained syncope (not pre-syncope)
Unexplained new onset of heart failure (e.g. without atherosclerotic coronary disease or other causes for cardiomyopathy)
Documented ventricular tachycardia (6 beat runs or greater)
Equivocal coronary artery anatomy on conventional cardiac catheterization
ABSENCE of ALL of the following:
Irregular heart rhythms (e.g. atrial fibrillation/flutter, frequent irregular premature ventricular contractions or premature atrial contractions, high grade heart block)
Obese individuals (body mass index greater than 40 kg/m2)
Elevated calcium score (calcium score greater than1000)
Renal insufficiency with creatinine greater than 1.8 mg/dl
Inability to follow breath holding instructions (e.g. patients with serious valve disease with marked dyspnea, patients with COPD)
Heart rate greater than 75 beats per minute
Allergy to iodine contrast material
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
According to the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) 2005 appropriateness criteria guidelines for pre-test probability:
High: Greater than 90% pre-test probability
Intermediate: Between 10% and 90% pre-test probability
Low: Between 5% and 10% pre-test probability
Very low: Less than 5% pre-test probability
Clinical data supporting the potential role for computed tomography angiography (CTA) for coronary artery evaluation for the treatment of other indications is lacking.
Considerable question remains as to whether coronary tomography angiography improves net health outcomes as well as any established imaging alternatives.
SOURCES
Achenbach, S., Ropers, D., Pohle, K., Anders, K., Baum, U., Hoffmann, U., et al. (2003). Clinical results of minimally invasive coronary angiography using computed tomography. Cardiology Clinics, 21 (4), 549-559.
Andreini, D., Pontone, G., Pepi, M., Ballerinim G., Bartorelli, A. L., Magini, A., et al. (2007). Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with dilated cardiomyopathy. Journal of the American College of Cardiology, 49 (20), 2044-2050.
Berbarie, R. F., Dockery, W. D., Johnson, K. B., Rosenthal, R. L., Stoler, R. C., & Schussler, J. M. (2006). Use of multislice computed tomographic coronary angiography for the diagnosis of anomalous coronary arteries. The American Journal of Cardiology, 98 (3), 402-406.
Brindis, R. G., Douglas, P. S., Hendel, R. C., Peterson, E. D., Wolk, M. J., Allen, J. M., et al. (2005). ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. Journal of the American College of Cardiology, 46 (8), 1587-1605.
Budoff, M. J., Achenbach, S., Blumenthal, R. S., Carr, J. J., Goldin, J. G., Greenland, P., et al. (2006). 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, 114 (16), 1761-1791.
Einstein, A. J., Henzlova, M. J., & Rajagopalan, S. (2007). Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA, 298 (3), 317-323.
Gibbons, R. J., Balady, G. J., Bricker, J. T., Chaitman, B. R., Fletcher, G. F., Froelicher, V. F., et al. (2002). ACC/AHA 2002 guideline update for exercise testing: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Journal of the American College of Cardiology, 40 (8), 1531-1540.
Hendel, R. C., Kramer, C. M., Patel, M. R., & Poon, M. (2006). ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for computed tomography and cardiac magnetic resonance imaging. Journal of the American College of Cardiology, 48 (7), 1475-1497.
Hoffmann, M. H., Shi, H., Schmitz, B. L., Schmid, F. T., Lieberknecht, M., Schulze, R., et al. (2005). Noninvasive coronary angiography with multislice computed tomography. JAMA, 293 (20), 2471-2478. (Level 2 Evidence - Industry sponsored)
Jacobs, J. E., Boxt, L. M., Desjardins, B., Fishman, E. K., Larson, P. A., Schoepf, J., et al. (2006). ACR practice guideline for the performance and interpretation of cardiac computed tomography (CT). Journal of the American College of Radiology, 3 (9), 677-685.
Meijboom, W. B., van Mieghem, C. A., Mollet, N. R., Pugliese, F., Weustink, A. C., van Pelt, N., et al. (2007). 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. Journal of the American College of Cardiology, 50 (15), 1469-1475. (Level 3 Evidence - Independent study)
Schlosser, T., Konorza, T., Hunold, P., Kuhl, H., Schermund, A., & Barkhausen, J. (2004). Noninvasive visualization of coronary artery bypass grafts using 16-detector row computed tomography. Journal of the American College of Cardiology, 44 (6), 1224-1229. (Level 3 Evidence - Independent study)
Schoenhagen, P., Halliburton, S. S., Stillman, A. E., Kuzmiak, S. A., Nissen, S. E., Tuzcu, E. M., et al. (2004). Noninvasive imaging of coronary arteries: Current and future role of multi-detector row CT. Radiology, 232 (1), 7-17.
Schoepf, U. J., Becker, C. R., Ohnesorge, B. M., & Yucel, E. K. (2004). CT of coronary artery disease. Radiology, 232 (1), 18-37.
Technology Evaluation Center. (2005, May). Contrast-enhanced cardiac computed tomographic angiography for coronary artery evaluation (Vol. 20, No. 4). Chicago: BlueCross BlueShield Association. (39 articles and/or guidelines reviewed)
Weinreb, J. C., Larson, P. A., Woodard, P. K., Stanford, W., Rubin, G. D., Stillman, A. E., et al. (2005). American College of Radiology clinical statement on noninvasive cardiac imaging. Journal of the American College of Radiology, 235 (3), 723-727.
ORIGINAL EFFECTIVE DATE: 8/13/2005
MOST RECENT REVIEW DATE: 12/1/2010
ID_MS
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