BlueCross BlueShield of Tennessee Medical Policy Manual

Coronary Computed Tomography Angiography (CCTA)

DESCRIPTION

Coronary computed tomography angiography (CCTA) is a noninvasive imaging test that requires the use of intravenously administered contrast material and high-resolution, high-speed computed tomography (CT) machinery to obtain detailed volumetric images of blood vessels. It has been suggested that CCTA may help rule out coronary artery disease (CAD) and avoid invasive coronary angiography in individuals with low-to-intermediate pretest probabilities of CAD.

Different types of CT technology that can achieve high-speed CT imaging:

• Electron beam computed tomography (EBCT, also known as ultrafast CT) uses a rotating electron gun rather than a standard x-ray tube.

• Helical CT scanning (also referred to as 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.

• Multidetector row helical CT (MDCT) or multi-slice CT scanning, is a technological 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 individual during a rapid volumetric image acquisition. MDCT machines currently in use have 64 or more detectors.

POLICY

• Coronary computed tomographic angiography is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

• Coronary computed tomographic angiography for all other indications is considered investigational.

MEDICAL APPROPRIATENESS

• Coronary computed tomographic angiography (CCTA) is considered medically appropriate if ALL of the following are met:

• • Indicated for ANY ONE of the following:

  • • Evaluation of suspected coronary artery disease if ALL of the following are met:

    • • Individuals with new, recurrent, or worsening symptoms concerning for cardiac ischemia

      • Intermediate or intermediate-high risk on the pre-test probability assessment (See table below)

      • Indicated for ANY ONE of the following:

      • • Persistent symptoms after stress test

        • Prior noninvasive evaluation (less than 90 days) with equivocal, borderline, abnormal or discordant results

        • Abnormal rest ECG findings (e.g., new left bundle branch block, T-wave inversions)

        • Prior CABG with only a concern for graft patency

    • After recovery from unexplained sudden cardiac arrest in lieu of invasive coronary angiography if ALL of the following are met:

    • • To confirm the presence or absence of ischemic heart disease

      • To exclude the presence of a coronary artery anomaly

    • Evaluation of bypass graft location for planned CABG revision

    • One-time follow-up at 6-12 months for left main stent

    • Symptomatic individual with unsuccessful conventional coronary angiography

    • Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels

    • Coronary artery anomalies suspected and ANY ONE of the following:

    • • Syncopal episodes during strenuous activities

      • Persistent exertional chest pain and normal stress test

      • Full sibling(s) with history of sudden death syndrome

      • Full sibling(s) with documented anomalous coronary artery

      • Resuscitated sudden death and contraindications for conventional coronary angiography

    • New diagnosis of congestive heart failure or cardiomyopathy if ALL of the following are met:

    • • No prior history of coronary artery disease

      • Ejection fraction less than 50 percent

      • Low or intermediate risk on pre-test probability assessment (see table below)

      • ABSENCE of ALL of the following since diagnosis

      • • Cardiac catheterization

        • SPECT

        • Cardiac PET

        • Stress echocardiogram

    • Equivocal coronary artery anatomy on conventional cardiac catheterization

    • Preoperative assessment of coronary arteries for ANY ONE of the following surgeries:

    • • Aortic dissection

      • Aortic aneurysm

      • Valvular surgery

    • Evaluation of coronary arteries in ANY ONE of the following conditions:

    • • Suspected Takotsubo syndrome (stress cardiomyopathy)

      • Hypertrophic cardiomyopathy

      • Vasculitis

      • Takayasu’s Disease

      • Kawasaki’s Disease

      • Ventricular tachycardia (6 beat runs or greater)

      • Cardiac trauma

IMPORTANT REMINDERS

• Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

• 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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

SOURCES

American College of Cardiology Foundation Task Force on Expert Consensus Documents, Mark, D. B., Berman, D. S., Budoff, M. J., Carr, J. J., Gerber, et al. (2010). ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Journal of the American College of Cardiology, 55 (23), 2663-2699. Retrieved April 26, 2022 from http://doi.org/10.1016/j.jacc.2009.11.013.

American College of Cardiology Foundation, Society of Cardiovascular Computed Tomography, American College of Radiology, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, North American Society for Cardiovascular Imaging, Society for Cardiovascular Angiography and Interventions, Society for Cardiovascular Magnetic Resonance. (November 2010). 2010 ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR appropriate use criteria for cardiac computed tomography. Retrieved September 8, 2016 from http://content.onlinejacc.org.

Andreini, D., Pontone, G., Pepi, M., Ballerini, G., Magini, A., Quaglia, C., et al. (2007). Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with dilated cardiomyopathy. Journal of American College of Cardiology, 49 (20), 2044-2050. Abstract retrieved October 30, 2017 from PubMed database.

Berbarie, R., Dockery, W., Johnson, K., Rosenthal, R., Stoler, R., & Schussler, J. (2006). Use of multislice computed tomographic coronary angiography for the diagnosis of anomalous coronary arteries. American Journal of Cardiology, 98 (3), 402-406. Abstract retrieved October 30, 2017 from PubMed database.

Budoff, M., Achenbach, S., Blumenthal, R., Carr, J., Goldin, J., 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, 1761-1791.

eviCore healthcare. (2023, February). Cardiac imaging policy. Retrieved April 17, 2023 from www.evicore.com. (31 articles and/or guidelines addressed).

Lyon, A. R., Bossone, E., Schneider, B., Sechtem, U., Citro, R., Underwood, S. R., et al. (2016). Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 18 (1), 8-27. Retrieved May 4, 2022 from https://www.escardio.org.

Schlosser, T., Konorza, T., Hunoid, P., Kuhl, H., Schermund, A., & Barkhausen, J. (2004). Noninvasive visualization of coronary artery bypass grafts using 16-detector row computed tomography. Journal of American Cardiology, 44 (6), 1224-1229. (Level 4 evidence)

Williams, M. C., Kwiecinski, J., Doris, M., McElhinney, P., D'Souza, M. S., Cadet, S., et al. (2020). Low-attenuation noncalcified plaque on coronary computed tomography angiography predicts myocardial infarction: Results from the multicenter SCOT-HEART Trial (Scottish computed tomography of the HEART). Circulation, 141 (18), 1452-1462. (Level 1 evidence)

ORIGINAL EFFECTIVE DATE:  8/13/2005

MOST RECENT REVIEW DATE:  6/8/2023

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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