Coronary Artery Calcium Scoring by Electron-Beam Tomography (EBCT) OR Non-Contrast Coronary Computed Tomography (Non-Contrast CCT) - CAM 378
Coronary artery calcium (CAC) testing is a cardiovascular risk assessment tool, applicable only to the patient without known cardiovascular disease, for the purpose of primary prevention. It is not for the patient with suspected or known cardiovascular disease, coronary or otherwise, who already requires aggressive risk factor modification.
CAC testing, by either EBCT or non-contrast CCT, provides a quantitative assessment of coronary artery calcium content in Agatston units, as an adjunct to the estimation of global risk for coronary or cardiovascular events over the next 10 years.7 A CAC Score > 0 is a highly specific feature of coronary atherosclerosis.
CAC score > 100 can also provide support for aspirin therapy5,18 and statin therapy.19
Patients who have already manifested cardiovascular disease are already at high global risk and the Global Cardiovascular Risk Calculators are not applicable.
Links to Global Cardiovascular Risk Calculators1,3,7,20,21
CAC testing is for cardiovascular risk assessment in individuals aged 40 – 75 years who have an intermediate (5 – 19.9%) 10-year ASCVD risk based upon the ACC/AHA pooled cohort risk calculator.
Documentation is required that the results of the study will affect decision making for preventative actions (i.e., statin therapy).
- Patients who are over 75 or younger than 40 years old can be considered for CAC testing when there is well-documented evidence of one of the following:11
- Patients with estimated 10-year risk of less than 5%, but are suspected to be at elevated atherosclerotic cardiovascular disease (ASCVD) risk because of a major
- risk factor not accounted for in the global risk equations, such as: 4,5,12
- Family history of premature ASCVD
- Persistently elevated LDL-C > 160 mg/dl or non-HDL-C >190 mg/dl
- Chronic kidney disease
- Metabolic syndrome
- Conditions specific to women (e.g., pre-eclampsia, premature menopause)
- Inflammatory diseases (HIV, psoriasis, RA)
- Ethnicity (e.g., South Asian ancestry)
- Persistently elevated triglycerides ( > 175 mg/dl)
- hsCRP > 2 mg/L
- Lp(a) levels > 50 mg/dl
- apoB > 130 mg/dl
- ABI < 0.9
- Patients in whom statin therapy is indicated, but have intolerable adverse effects from, or are reluctant to take statin medication, in order to guide the need for alternative lipid-lowering strategies. 2,8,13
- CAC scoring should be performed in asymptomatic patients. It should not be used as a diagnostic test in patients with symptoms suggestive of ischemia.
- Patients with known CAD should not be considered for calcium scoring as the results are unlikely to affect treatment.5,13-15
- CAC testing may be repeated for risk re-assessment after a minimum of 5 years, if documentation indicates it will alter management.4,5,13 It should not be repeated if the patient already has two CAC scores of zero 5 years apart or has a score ≥ 4004.
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Sep 10 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010
- Blankstein R, Gupta A, Rana JS, Nasir K. The Implication of Coronary Artery Calcium Testing for Cardiovascular Disease Prevention and Diabetes. Endocrinol Metab (Seoul). Mar 2017;32(1):47-57. doi:10.3803/EnM.2017.32.1.47
- Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Jul 1 2014;63(25 Pt B):2935-2959.doi:10.1016/j.jacc.2013.11.005
- Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary Calcium Score and Cardiovascular Risk. J Am Coll Cardiol. Jul 24 2018;72(4):434-447.doi:10.1016/j.jacc.2018.05.027
- Hecht H, Blaha MJ, Berman DS, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. Mar-Apr 2017;11(2):157-168. doi:10.1016/j.jcct.2017.02.010
- Mahabadi AA, Möhlenkamp S, Lehmann N, et al. CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines. JACC Cardiovasc Imaging. Feb 2017;10(2):143-153. doi:10.1016/j.jcmg.2016.03.022
- McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study). J Am Coll Cardiol. Oct 13 66(15):1643-53. doi:10.1016/j.jacc.2015.08.035
- Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. Oct 13 2015;66(15):1657-68. doi:10.1016/j.jacc.2015.07.066
- Pender A, Lloyd-Jones DM, Stone NJ, Greenland P. Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions. J Am Coll Cardiol. Oct 11 2016;68(15):1690-1697. doi:10.1016/j.jacc.2016.07.753
- Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. Aug 1 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
- Tota-Maharaj R, Blaha MJ, McEvoy JW, et al. Coronary artery calcium for the prediction of mortality in young adults <45 years old and elderly adults >75 years old. Eur Heart J. Dec 2012;33(23):2955-62. doi:10.1093/eurheartj/ehs230
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 06 18 2019;139(25):e1046-e1081. doi:10.1161/CIR.0000000000000624
- Michos ED, Blaha MJ, Blumenthal RS. Use of the Coronary Artery Calcium Score in Discussion of Initiation of Statin Therapy in Primary Prevention. Mayo Clin Proc. Dec 2017;92(12):1831-1841. doi:10.1016/j.mayocp.2017.10.001
- Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Jul 1 2014;63(25 Pt B):2889-934. doi:10.1016/j.jacc.2013.11.002
- Wilkins JT, Lloyd-Jones DM. USPSTF Recommendations for Assessment of Cardiovascular Risk With Nontraditional Risk Factors: Finding the Right Tests for the Right Patients. Jama. Jul 17 2018;320(3):242-244. doi:10.1001/jama.2018.9346
- § 59A-23-7.16. Heart artery calcium scan coverage. Legislature of the State of New Mexico.Updated March 9, 2020. Accessed July 8, 2022. https://www.nmlegis.gov/Sessions/20%20Regular/final/HB0126.pdf
- Insurance code: Title 8. Health insurance and other health coverages. Chapter 1376. Certain tests for early detection of cardiovascular disease. Texas State Legislature. Accessed August 3, 2022. https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1376.htm
- Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. May 2014;7(3):453-60. doi:10.1161/circoutcomes.113.000690 .
- Mortensen MB, Falk E, Li D, et al. Statin Trials, Cardiovascular Events, and Coronary Artery Calcification: Implications for a Trial-Based Approach to Statin Therapy in MESA. JACC Cardiovasc Imaging. Feb 2018;11(2 Pt 1):221-230. doi:10.1016/j.jcmg.2017.01.029
- Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. Jama. Feb 14 2007;297(6):611-9. doi:10.1001/jama.297.6.611
- D'Agostino RB, Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. Feb 12 2008;117(6):743-53. doi:10.1161/circulationaha.107.699579
- Blaha MJ, Matsushita K. Coronary Artery Calcium: Need for More Clarity in Guidelines. JACC Cardiovasc Imaging. Feb 2017;10(2):154-156. doi:10.1016/j.jcmg.2016.05.017
- Nasir K, Shaw LJ, Budoff MJ, Ridker PM, Peña JM. Coronary artery calcium scanning should be used for primary prevention: pros and cons. JACC Cardiovasc Imaging. Jan 2012;5(1):111-8. doi:10.1016/j.jcmg.2011.11.007
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.
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History From 2022 Forward
|04/19/2023||Interim review. Corrected typo in medical necessity bullet points.|