BlueCross BlueShield of Tennessee Medical Policy Manual

Computed Tomography to Detect Coronary Artery Calcification (i.e., calcium scoring)


Several types of fast computed tomography (CT) imaging, including electron beam (EBCT), helical, multislice spiral, or multidetector row, allow the quantification of calcium (i.e., calcium scoring) in coronary arteries.  Coronary artery calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not cause ischemia or symptoms.  The most widely studied indication for the use of calcium scoring is the prediction of future risk for coronary artery disease in individuals with subclinical disease. In addition, calcium scoring has been evaluated in individuals with symptoms potentially consistent with coronary artery disease, but in whom a diagnosis is unclear.





Typical angina is described as substernal chest pain or discomfort (e.g., pressure, heaviness, burning or tightness) generally brought on by exertion or emotional stress that may radiate to the left arm or jaw.

There remains a lack of high-quality evidence demonstrating improved outcomes from the use of coronary artery calcium scoring as a screening tool in asymptomatic individuals.


American College of Cardiology Foundation. (2006). ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. Retrieved April 16, 2020 from

American College of Cardiology Foundation. (2007). ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain. Retrieved April 17, 2020 from

American College of Cardiology Foundation. (2014). ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. Retrieved May 28, 2019 from

American College of Cardiology/American Heart Association. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Retrieved May 28, 2019 from

American College of Radiology. (2013). ACR Appropriateness Criteria® asymptomatic patient at risk for coronary artery disease. Retrieved May 28, 2019 from

American College of Radiology. (2018). ACR appropriateness criteria® chronic chest pain – low to intermediate probability of coronary artery disease. Retrieved May 28, 2019 from

BlueCross BlueShield Association. Evidence Positioning System. (10:2020). Computed tomography to detect coronary artery calcification. (6.01.03). Retrieved December 28, 2020 from (39 articles and/or guidelines reviewed)

Budoff, M., Mayrhofer, T., Ferencik, M., Bittner, D., Lee, K., Lu, M., et al. (2017). The prognostic value of coronary artery calcium in the PROMISE study. Circulation, 126 (31), 1993-2005. (Level 1 evidence)

Cainzos-Achirica, M., Bittencourt, M.S., Osei, A.D., Haque, W., Bhatt, D.L., Blumenthal, R.S., et al. (2020). Coronary artery calcium to improve the efficiency of randomized controlled trials in primary cardiovascular prevention. JACC: Cardiovascular Imaging, S1936-878X (20) 30938-4. doi: 10.1016/j.jcmg.2020.10.016. Abstract retrieved December 29, 2020 from PubMed database.

Cho, I., Ó Hartaigh, B., Gransar, H., Valenti, V., Lin, F.Y., Achenbach, S., et al. (2016). Prognostic implications of coronary artery calcium in the absence of coronary artery luminal narrowing. Atherosclerosis, 262, 185-190. Abstract retrieved May 4, 2018 from PubMed database.

eviCore Healthcare. (2020, October). Clinical guidelines: cardiac imaging policy, version 2.1. Retrieved December 28, 2020 from

Lubbers, M., Dedic, A., Coenen, A., Galema, T., Akkerhuis, J., Bruning, T., et al. (2016). Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial.  European Heart Journal, 37 (15), 1232-1243. (Level 2 evidence)

National Institute for Health and Clinical Excellence. (2016). Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Retrieved April 14, 2020 from   

Paixao, A. R., Ayers, C. R., El Sabbagh, A., Sanghavi, M., Berry, J. D., Rohatgi, A., et al. (2015). Coronary artery calcium improves risk classification in younger populations. Journal of the American College of Cardiology, 8 (11), 1285-1293. Abstract retrieved February 22, 2017 from PubMed database.

Palmetto Government Benefit Administrators. (2019, October). LCD for cardiac computed tomography & angiography (CCTA (L33423). Retrieved December 28, 2020 from

Peters, S., den Ruijter, H., Bots, M., & Moons, K. (2012). Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review. Heart, 98, 177-184. (Level 1 evidence)

U. S. Preventive Services Task Force. (2018, July). Risk assessment for cardiovascular disease with nontraditional risk factors: U. S. Preventive Services Task Force recommendation statement. Retrieved April 17, 2020 from

Winifred S. Hayes, Inc. Medical Technical Directory. (2017, February; last update search May 2020). Coronary artery calcium scoring for risk assessment and stratification of coronary artery disease in asymptomatic adults. Retrieved December 28, 2020 from (58 articles and/or guidelines reviewed)




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