This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Utilization of cardiovascular imaging in emergency department patients with chest pain may be considered for the following:

ACCF et al. Criteria # CCTA (Indication and Appropriate Use Score)	INDICATIONS (*Refer to Additional Information section)
	Detection of Coronary Artery Disease (CAD) in Symptomatic Patients Without Known Heart Disease
	Stable/Nonacute Symptoms Possibly Representing an Ischemic Equivalent
1 I(1-3)	Low pretest probability of CAD*; and Electrocardiogram (ECG) interpretable and able to exercise.
1 U(4-6)	Intermediate pretest probability of CAD*; and ECG interpretable AND able to exercise.
2 U(4-6)	Low pretest probability of CAD*; and ECG uninterpretable or unable to exercise.
2 A(8)	Intermediate pretest probability of CAD*; and ECG uninterpretable or unable to exercise.
2 U(4-6)	High pretest probability of CAD*; and Regardless of ECG interpretability and ability to exercise.
	Acute Symptoms With Suspicion of Acute Coronary Syndrome (ACS) (Urgent Presentation) after Standard Evaluation Has Not Resulted in an Actionable Diagnosis
4 U(6)	Persistent ECG ST-segment elevation following exclusion of myocardial infarction (MI) by invasive coronary arteriography.
5 A(7-9)	If ONE of the following apply: Acute chest pain of uncertain cause (differential diagnosis includes pulmonary embolism, aortic dissection, and ACS ["triple rule out"]); or Equivocal diagnosis due to single troponin elevation without additional evidence of ACS; or Equivocal diagnosis with ischemic symptoms resolved hours before testing; or Low-to-intermediate likelihood of ACS based upon TIMI RISK Score = 0, with early high sensitivity troponin negative; or Low-to-intermediate likelihood of ACS based upon normal/nonischemic initial EKG and normal initial troponin; or SERIAL EKGS and troponins negative or if either is borderline for non—ST-segment elevation myocardial infarction (NSTEMI)/ACS.
5 U(4-6)	Diagnosis unequivocally positive for ACS, but this category should be reserved for patients in whom invasive coronary arteriography would be considered at least relatively contraindicated.
	Acute Symptoms with Suspicion of ACSx (Urgent Presentation), when the History Reveals A Particular Pretest Probability.
6 Low/Int Pretest probability* A(7) High Pretest probability* U(4)	Acute symptoms, possibly representing an ischemic equivalent; and Normal ECG and cardiac biomarkers (troponin and CPK/CPK-MB).
7 Low/Int Pretest probability* A(7) High Pretest probability* U(4)	Acute symptoms, possibly representing an ischemic equivalent; and ECG uninterpretable.
8 Low/Int Pretest probability* A(7) High Pretest probability* U(4)	Acute symptoms, possibly representing an ischemic equivalent; and Nondiagnostic ECG or equivocal cardiac biomarkers.
	Additional CAD/Risk Assessment, Based Upon Pre-existing GLOBAL RISK, in ASYMPTOMATIC Individuals Without Known CAD
	Noncontrast CT for Coronary Calcium Score
10 Intermediate Global Risk (10-20%, or 6-20% in women and younger men)** U(4-6)	If ALL the following apply: Risk assessment in asymptomatic patients (not for diagnosis in symptomatic patients); and No known CAD; and Result could change management of coronary risk.
	Coronary CTA with Contrast in the Asymptomatic Individual
10 High Global Risk (>20%) U(4-6)	If ALL the following apply: Risk assessment in asymptomatic patients; and No known CAD; and Not a candidate for EKG stress testing alone due to inability to exercise or an uninterpretable EKG; and Not a candidate for stress echocardiography due to inability to exercise; and Result could change management of coronary risk.
	Coronary CTA Following Heart Transplantation
12 U(6)	Routine evaluation of coronary arteries for transplant vasculopathy.
	Detection of CAD in Other Clinical Scenarios
	New-Onset or Newly Diagnosed Clinical Heart Failure (HF) and No Prior CAD
13 Newly  Diagnosed Heart Failure A(7-9)	Reduced left ventricular ejection fraction (EF) (less than 40% EF), when invasive coronary arteriography is not the preferred method of evaluation.
14 Newly Diagnosed Heart Failure U(4-6)	Normal left ventricular EF.
	Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
15 A(7-9)	If ALL the following apply: Coronary evaluation before thoracoabdominal aortic surgery; and Patient has less than a  4 MET functional capacity; and Patient has ONE (1) peri-operative risk factor; and No coronary evaluation (invasive or non-invasive) within the past year; and If invasive coronary arteriography is preferable, then CCTA is not appropriate; and Alternatively, without the need for the above criteria, patient would be a candidate for CCTA at the time of a preoperative evaluation if indications unrelated to the surgery were well documented in the clinical record.
	Arrhythmias-Etiology Unclear After Initial Evaluation
17 (1-3)	Any ONE of the following: Infrequent premature ventricular contractions (PVCs); or New Onset atrial fibrillation.
17 U(4-6)	Any ONE of the following: Exercise induced or nonsustained ventricular tachycardia; or Ventricular fibrillation; or Sustained ventricular tachycardia (VT); or Frequent PVCs (greater than 30/hr); or Prior to initiation of antiarrhythmic therapy in high global risk CAD patients.
18 I(1-3)	Syncope Low Global CAD risk.
18 U(4-6)	Syncope Intermediate and High global CAD risk** initial evaluation includes echocardiogram.
	Elevated Troponin of Uncertain Clinical Significance
19 U(6)	Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD.
	Use of CTA in the Setting of Prior Test Results
	Prior ECG or ECG Exercise Testing
20 A(7)	Normal ECG exercise test; and Continued symptoms.
21 A(7)	Prior ECG exercise; and Intermediate mortality risk***based upon Duke Treadmill Score.
U(4-6)	Abnormal rest ECG (highly concerning for ischemia, without clear indication for invasive coronary arteriography). LEFT BUNDLE BRANCH BLOCK, when the history, physical examination, and/or noninvasive EF together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress imaging (myocardial perfusion imaging (MPI) or echo).
	Sequential Testing After Stress — Imaging Procedures
22 A(8)	Discordant ECG exercise and imaging results.
23 Equivocal for Ischemia A(8) Mild Ischemia U(6)	Prior stress ECG or stress imaging results:
	Prior CCS
	No longer applicable. Use MESA Global Risk Calculator and base decision on Global Risk.
	Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study
29 A(7-9)	Previous stress ECG or stress imaging study abnormal when a noninvasive approach is preferable to proceeding to invasive coronary arteriography (unclear nature of symptoms, mildly abnormal or borderline EKG stress test or stress with echocardiogram/MPI, CKD, dye allergy, etc.) Previous stress ECG study normal when a noninvasive approach is preferable to proceeding to invasive coronary arteriography (unclear nature of symptoms, mildly abnormal or borderline EKG stress test or stress with echocardiogram/MPI, CKD, dye allergy, etc.) Previous stress imaging study normal within the past 2 years and currently compelling coronary history or symptoms should be considered appropriate indication for a CCTA, particularly if there are reasons to avoid cardiac catheterization (CKD, dye allergy, etc.), unless invasive coronary arteriography is strongly indicated (e.g. compelling presentation of moderate or high risk unstable angina).
	Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions
	Intermediate-Risk Surgery
	See indication #15.
	Vascular Surgery
	See indication #15.
	Risk Assessment Post revascularization (PCI or CABG)
	Symptomatic (Ischemic Equivalent) Post Coronary Revascularization
39 U(4-6)	Evaluation of graft patency after coronary artery bypass grafting surgery (CABG) or evaluation post percutaneous coronary intervention, with good documentation of symptomatic presentation, are indications for CCTA if it could affect management.
	Asymptomatic-Post Coronary Revascularization
42 U(4-6)	Prior left main coronary stent.
	Evaluation of Cardiac Structure and Function
	Adult Congenital Heart Disease
46 A(9)	Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels. This includes long term follow-up of Kawasaki disease for aneurysm formation.♦ (♦ For “localization of coronary bypass grafts” CCTA preferred and for “other retrosternal anatomy” Heart CT preferred).
	Evaluation of Intra- and Extracardiac Structures
60 A(8)	Localization of coronary bypass grafts and other retrosternal Anatomy.♦ Prior to preoperative chest or cardiac surgery. (♦ For “localization of coronary bypass grafts” CCTA preferred and for “other retrosternal anatomy” Heart CT preferred).

CCTA may be considered medically necessary for the following:

• CCTA may be appropriately used when evaluating chest pain syndromes with low to intermediate risk CAD profiles such as in emergency room or observation unit situations; or
• CCTA may be an appropriate substitution exam for a left heart catheterization; or
• CCTA may be appropriate prior to transcatheter aortic valve replacement (TAVR) as an alternative to coronary arteriography.

The patient must meet American College of Cardiology Foundation/American Heart Association Task Force (ACCF/ASNC) Appropriateness criteria for inappropriate indications (median score 1 – 3) below or meets any ONE of the following:

• Contraindications to beta blockers used to slow heart rate during procedure; or
• Acute chest pain/angina; or
• Pre-op request for non-cardiac surgery; or
• Significant premature ventricular contractions, significant frequent atrial fibrillation, or relative contra-indication to CCTA.

ACCF/ American Society of Nuclear Cardiology (ASNC)/ American College of Radiology (ACR)/ American Heart Association (AHA)/ American Society of Echocardiography (ASE)/ Society of Cardiovascular Computed Tomography (SCCT)/ Society for Cardiovascular Magnetic Resonance (ACMR)/ Society of Nuclear Medicine (SNM) 2010 appropriate use score criteria:

ACCF et al. Criteria # CCTA		INDICATIONS   (*Refer to Additional Information section)	APPROPRIATE USE SCORE (1-3); I= Inappropriate
		Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic
		Non-acute Symptoms Possibly Representing an Ischemic Equivalent
1		High pretest probability of CAD*. ECG interpretable and able to exercise.	I(3)
		Acute Symptoms With Suspicion of ACS (Urgent Presentation)
3		Definite MI.	I(1)
		Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD
		Noncontrast CT for CCS
10		Low global congenital heart disease (CHD) risk estimate.**	I(2)
		Coronary CTA
11		Low or Intermediate global CHD risk estimate.**	I(2)
		Detection of CAD in Other Clinical Scenarios
		Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
15		High pretest probability of CAD.* Coronary evaluation before noncoronary cardiac surgery.	I(3)
		Arrhythmias-Etiology Unclear After Initial Evaluation
16		New-onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging.	I(2)
		Use of CTA in the Setting of Prior Test Results
		ECG Exercise Testing
21		Prior ECG exercise testing. Duke Treadmill Score*** -low risk findings.	I(2)
21		Prior ECG exercise testing. Duke Treadmill Score***—high risk findings.	I(3)
		Sequential Testing After Stress — Imaging Procedures
23		Stress imaging results: moderate or severe ischemia.	I(2)
		Prior CCS
25		Positive Coronary Calcium Score greater than two (2) years ago.	I(2)
	Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress Imaging or Coronary Angiography
27	No known CAD. Last study done less than two (2) years ago.		I(2)
27	No known CAD. Last study done greater than or equal to two (2) years ago.		I(3)
28	Known CAD. Last study done less than two (2) years ago.		I(2)
28	Known CAD Last study done greater than or equal to two (2) years ago.		I(3)
	Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions
	Low-Risk Surgery
30	Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity.		I(1)
	Intermediate-Risk Surgery
31	No clinical risk predictors.		I(2)
32	Functional capacity greater than or equal to 4 METs.		I(2)
34	Asymptomatic less than one (1) year following a normal coronary angiogram, stress test, or a coronary revascularization procedure.		I(1)
	Vascular Surgery
35	No clinical risk predictors.		I(2)
36	Functional capacity greater than or equal to 4 METs.		I(2)
38	Asymptomatic less than one (1) year following a normal coronary angiogram, stress test, or a coronary revascularization procedure.		I(2)
	Risk Assessment Post revascularization (PCI or CABG)
	Symptomatic (Ischemic Equivalent)
40	Prior coronary stent with stent diameter less than 3 mm or not known.		I(3)
	Asymptomatic CABG
42	Prior coronary bypass surgery less than five (5) years ago.		I(2)
	Asymptomatic- Prior Coronary Stenting
44	Prior coronary stent with stent diameter less than 3 mm or not known.		I(2)
45	Prior coronary stent with stent diameter greater than or equal to 3 mm. Less than two (2) years after PCI.		I(3)
	Evaluation of Cardiac Structure and Function
	Evaluation of Ventricular Morphology and Systolic Function
48	Initial evaluation of left ventricular function. Following acute MI or in HF patients.		I(2)
	Evaluation of Intra- and Extracardiac Structures
55	Initial evaluation of cardiac mass (suspected tumor or thrombus).		I(3)

*Pretest Probability of CAD for Symptomatic (Ischemic Equivalent) Patients:

• Typical Angina (Definite): Defined as:
  • Substernal chest pain or discomfort that is provoked by exertion or emotional stress; and
  • Relieved by rest and/or nitroglycerin.
• Atypical Angina (Probable): Chest pain or discomfort that lacks ONE (1) of the characteristics of definite or typical angina.
• Nonanginal Chest Pain: Chest pain or discomfort that meets ONE (1) or none of the typical angina characteristics.

Once the presence of symptoms (Typical Angina/Atypical Angina/Non angina chest pain/Asymptomatic) is determined, the pretest probabilities of CAD can be calculated from the risk algorithms as follows:

Age (Years)	Gender	Typical/Definite Angina Pectoris	Atypical/Probable Angina Pectoris	Nonanginal Chest Pain	Asymptomatic
Less than 39	Men	Intermediate	Intermediate	Low	Very low
	Women	Intermediate	Very low	Very low	Very low
40–49	Men	High	Intermediate	Intermediate	Low
	Women	Intermediate	Low	Very low	Very low
50–59	Men	High	Intermediate	Intermediate	Low
	Women	Intermediate	Intermediate	Low	Very low
Greater than 60	Men	High	Intermediate	Intermediate	Low
	Women	High	Intermediate	Intermediate	Low

**Global CAD Risk:

It is assumed that clinicians will use current standard methods of global risk assessment in the asymptomatic patient for primary prevention, based upon Framingham-ATP IV, Reynolds, Pooled Cohort Equation (includes cerebrovascular risk), ACC/AHA Risk Calculator, MESA Risk Calculator (includes calcium score), or very similar risk calculator) CAD risk refers to ten (10)-year risk for any hard cardiac event (e.g., myocardial infarction (MI) or CAD death).

• Low global CAD risk
  • Defined by the age-specific risk level that is below average. In general, low risk will correlate with a ten (10)-year absolute CAD risk less than 10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk less than 6%.
• Intermediate global CAD risk
  • Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a ten (10)-year absolute CAD risk range of 10% to 20%. Among women and younger age men, an expanded intermediate risk range of 6% to 20% may be appropriate.
• High global CAD risk
  • Defined by the age-specific risk level that is above average. In general, high risk will correlate with a ten (10)-year absolute CAD risk of greater than 20%. CAD equivalents (e.g., peripheral arterial disease (defined in additional information), cerebrovascular disease (history of stroke or TIA), or multiple simultaneous anti-rejection medications (e.g. cyclosporine, tacrolimus, mycophenolate mofetil, azathioprine, long term supraphysiologic doses of glucocorticoids, but not everolimus or sirolimus/rapamycin), peripheral arterial disease) can also define high risk. High global risk can be further defined by compelling non-invasive data, such as clearly pathologic Q waves on the EKG, marked ST-segment and/or T wave abnormalities of myocardial ischemia without symptoms, clear regional wall motion abnormalities of the left ventricle, or reduced EF below 50%.

***Duke Treadmill Score

• The equation for calculating the Duke treadmill score (DTS) is:
• DTS = exercise time - (5 * ST deviation) - (4 * exercise angina), with 0 = none, 1 = non limiting, and 2 = exercise-limiting.
• The score typically ranges from -25 to +15. These values correspond to low-risk (with a score of >/= +5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of </= -11) categories. The Duke Score provides an annual mortality estimate: less than 1% for low risk, 1-3% for intermediate risk, and greater than 3% for high risk.

CTA for all other clinical indications and applications is considered not medically necessary.

The purpose of Fractional Flow Reserve (FFR) is to determine if an invasive cardiac catheterization (ICA) can be avoided.

FFR-CT may be considered medically necessary when ALL of the following are met:

• Prior to CCTA, the patient was stable with a pre-test probability between 20% and 80% of significant, ischemia-producing CAD, based upon reliable calculations, (i.e., Diamond Forrester, ESC Consortium, University of Washington, or similar calculators.); and
• The patient had at least ONE of the following scenarios:
  • A pretest probability of 20-50% (low-to-moderate) prior to CCTA and was selected for evaluation with CCTA as a non-invasive test for significant CAD. The CCTA result shows lesions of greater than or equal to 50%; or
  • A pretest probability of 51-80% (moderate or high moderate) prior to CCTA and was selected for evaluation with CCTA as a non-invasive test for significant CAD. The CCTA result shows lesions of 30-50%.

FFR-CT for the following clinical scenarios are considered experimental/investigational and, therefore, non-covered. FFR-CT has not been adequately validated due to inapplicability of computational dynamics, artifacts, and/or clinical circumstances:

• Suspicion or current presentation of an ACS unless the patient has unstable angina, MI was excluded, and invasive coronary artery (ICA) would not be recommended if FFR-CT were negative
• Known ischemic CAD that has not been revascularized and there has been no change in the patient status or in the CCTA images
• Recent MI within 30 days
• Prior CBGA
• Patients required emergent or urgent ICA, or have any evidence of ongoing or active clinical instability, including acute chest pain (sudden onset), cardiogenic shock, unstable blood pressure  with systolic blood pressure  less than 90 mmHg, severe CHF (New York Heart Association [NYHA] III or IV) or acute pulmonary edema
• Complex CHD or ventricular septal defect (VSD) with Qp/Qs greater than 1.4
• Body Mass Index (BMI) greater than 35
• Metallic stents in the coronary system
• Coronary vessels with extensive or heavy calcification
• Coronary lesions needing evaluation in which vessel diameter is less than 1.8 mm
• Cardiac implanted electrical devices (CIEDs)
• Prosthetic heart valves
• Severe wall motion abnormality on CCTA results
• Severe myocardial hypertrophy
• High risk indicators on stress test
• ICA within the past 90 days
• Marginal quality of the submitted imaging data, due to motion, blooming, misalignment, arrhythmia, etc.

Note: The analysis requires a CCTA with at least a 64-slice capability and good-quality images.

CTA coronary arteries and fractional flow reserve CT is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Provider Resource Center for the Medical Policy Update

10/2017, New Coverage Criteria and Policy Title Change for Cardiac Computed Tomography (Cardiac CT)

11/2017, Radiology Management Program Update

12/2017, Correction: Title and Criteria Revised for Cardiac Computed Tomography (Cardiac CT)

• Link to References