CTA Coronary Arteries (CCTA) - CAM 765

Description/Background
Coronary computed tomographic angiography (CCTA) is a noninvasive imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging computed tomography (CT).22,23

Stable patients without known CAD fall into 2 categories:1,2,4

  • Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Risk Calculators in the Overview section).
  • Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant CAD.

Three Types of Chest Pain or Discomfort:

  • Typical angina (definite) is defined as including ALL 3 characteristics:
    • Substernal chest pain or discomfort with characteristic quality and duration
    • Provoked by exertion or emotional stress
    • Relieved by rest and/or nitroglycerin
  • Atypical angina (probable) has only 2 of the above characteristics.
  • Nonanginal chest pain/discomfort has only 0 – 1 of the above characteristics.
  • Once the type of chest pain has been established from the medical record, the pretest probability of significant CAD is estimated from the Diamond Forrester Table below, recognizing that additional coronary risk factors could increase pretest probability.4

Diamond Forrester Table

Age (Years)

Gender

Typical/Definite Angina Pectoris

Atypical/Probable Angina Pectoris

Nonanginal Chest Pain

39

Men

Intermediate

Intermediate

Low

Women

Intermediate

Very low

Very low

40 – 49

Men

High

Intermediate

Intermediate

Women

Intermediate

Low

Very low

50 – 59

Men

High

Intermediate

Intermediate

Women

Intermediate

Intermediate

Low

60

Men

High

Intermediate

Intermediate

Women

High

Intermediate

Intermediate

o    Very Low: < 5% pretest probability of CAD
o    Low: 5% – 10% pretest probability of CAD
o    Intermediate: 10% – 90% pretest probability of CAD
o    High: > 90% pretest probability of CAD

 

General Information

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.
 

Policy
INDICATIONS FOR CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY (CCTA)1,2,3,4
Evaluation in Suspected Coronary Artery Disease (CAD)5,6,7,8

  • Intermediate and high pretest probability patients9
  • Low pretest probability patients should be considered for exercise treadmill test (ETT) unless other criteria for CCTA are met
  • Symptomatic patients with prior PCI (stents > 3mm) or CABG history
  • Exercise ECG stress test with intermediate Duke Treadmill (-10 to +4)
  • Equivocal, borderline, or discordant stress imaging evaluation with continued symptoms concerning for CAD
  • Repeat testing in patient with new or worsening symptoms since prior normal stress imaging3,4
  • Asymptomatic patients without known CAD
    • Previously unevaluated ECG evidence of possible myocardial ischemia including ischemic ST segment or T wave abnormalities (see overview section)
    • Previously unevaluated pathologic Q waves (see overview section)
    • Previously unevaluated left bundle branch block
  • Newly diagnosed clinical systolic heart failure or diastolic heart failure, with reasonable suspicion of cardiac ischemia (prior events, risk factors), unless invasive coronary angiography is planned (SE diversion not required)3,4,10,11,12
  • Before valve surgery or transcatheter intervention as an alternative to coronary angiography13,14,15
  • To establish the etiology of mitral regurgitation15
  • Evaluation of coronary anomaly or aneurysm16,17,18,19
    • Evaluation prior to planned repair
    • Evaluation due to change in clinical status and/or new concerning signs or symptoms
    • Kawasaki disease and MIS-C follow up – for medium sized or greater aneurysms20 periodic surveillance can be considered every 2 – 5 years. Once aneurysmal size has reduced to small aneurysms, surveillance can be performed every 3 – 5 years. No further surveillance once normalized.
  • Evaluation of coronary artery bypass grafts, to assess:3,21
    • Patency and location when invasive coronary arteriography was either nondiagnostic or not performed
    • Location prior to cardiac or another chest surgery

Electrophysiologic Procedure Planning

  • Evaluation of anatomy prior to radiofrequency ablation

OVERVIEW
The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain has given a Class 1 recommendation with level of evidence of A for patients with stable and acute chest pain, who have no known coronary artery disease (CAD).9

Patient selection and contraindications to CCTA must be considered and may be inappropriate for the following:

  • Known history of severe and/or anaphylactic contrast reaction
  • Inability to cooperate with scan acquisition and/or breath-hold instructions
  • Pregnancy
  • Clinical instability (e.g., acute myocardial infarction, decompensated heart failure, severe hypotension)
  • Renal impairment as defined by local protocols
  • Image quality depends on keeping HR optimally < 60 bpm, a regular rhythm, limited coronary calcification, stents > 3.0 mm in diameter, ≥ 5 second breath hold, and vessels requiring imaging ≥ 1.5 mm diameter.24

Scenarios that can additionally support a CCTA over a regular exercise treadmill test in the low probability scenario25

Inability To Exercise

  • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
  • The patient has limited functional capacity (< 4 METS) such as ONE of the following:
    • Unable to take care of their activities of daily living (ADLs) or ambulate
    • Unable to walk 2 blocks on level ground
    • Unable to climb 1 flight of stairs
    • Unable to vacuum, dust, do dishes, sweep, or carry a small grocery bag

Other Comorbidities

  • Prior cardiac surgery (coronary artery bypass graft or valvular)
  • Left ventricular ejection fraction ≤ 50%
  • Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
  • Poorly controlled hypertension, with systolic blood pressure (BP) > 180 or Diastolic BP > 120

ECG and Echo-Related Baseline Findings

  • Pacemaker or implantable cardioverter defibrillator (ICD)
  • Resting wall motion abnormalities on echocardiography
  • Complete LBBB

Risk-Related

  • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs
  • Arrhythmia risk with exercise

ECG Stress Test Alone versus Stress Testing with Imaging
Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise:4

  • The (symptomatic) low pretest probability patient who can exercise and has an interpretable ECG4
  • The patient who is under evaluation for exercise-induced arrhythmia
  • The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
  • For the evaluation of syncope or presyncope during exertion26

Duke Exercise ECG Treadmill Score27

Calculates risk from ECG treadmill alone:

  • The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 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

An uninterpretable baseline ECG includes1:

  • ST segment depression of 1 mm or more (not for non-specific ST - T wave changes)
  • Ischemic looking T wave inversions of at least 2.5 mm
  • LVH with repolarization abnormalities, WPW, a ventricular paced rhythm, or left bundle branch block
  • Digitalis use with associated ST - T abnormalities
  • Resting HR under 50 bpm on a beta blocker and an anticipated suboptimal workload
  • Note: RBBB with less than 1 mm ST depression at rest may be suitable for ECG treadmill testing
  • Previously unevaluated pathologic Q waves (in two contiguous leads) defined as the following:
    • > 40 ms (1 mm) wide
    • > 2 mm deep
    • > 25% of depth of QRS complex

Global Risk of Cardiovascular Disease

Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years.

High global risk by itself generally lacks scientific support as an indication for stress imaging.5
 
There are rare exemptions, such as patients requiring IC antiarrhythmic drugs, who might require coronary risk stratification prior to initiation of the drug, when global risk is moderate or high.

  • CAD Risk — Low 10 - year absolute coronary or cardiovascular risk less than 10%
  • CAD Risk — Moderate 10 - year absolute coronary or cardiovascular risk between 10% and 20%
  • CAD Risk — High  10 - year absolute coronary or cardiovascular risk of greater than 20%

Websites for Global Cardiovascular Risk Calculators*

Risk Calculator

Websites for Online Calculator

Framingham

Cardiovascular Risk

https://reference.medscape.com/calculator/framingham-

cardiovascular-disease-risk

Reynolds Risk Score Can use if no diabetes Unique for use of family history

http://www.reynoldsriskscore.org/

Pooled Cohort Equation

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx?example

ACC/AHA Risk Calculator

http://tools.acc.org/ASCVD-Risk-Estimator/

MESA Risk Calculator With addition of Coronary Artery Calcium Score, for CAD-only risk

https://www.mesa- nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx


*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.28,29,30,31,32

Definitions of Coronary Artery Disease1,2,33,34,35

  • Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).
  • Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. It is not a diagnostic tool so much as it is a risk stratification tool. Its incorporation into global risk can be achieved by using the MESA risk calculator. 
  • Stenoses ≥ 70% are considered obstructive coronary artery disease (also referred to as clinically significant), while stenoses ≤ 70% are considered non-obstructive coronary artery disease.33
  • Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
    • Suggested by percentage diameter stenosis ≥ 70% by angiography; intermediate lesions are 50% – 69%36
    • For a left main artery, suggested by a percentage stenosis ≥ 50% or minimum luminal cross-sectional area on IVUS ≤ 6 square mm1,35,37
    • FFR (fractional flow reserve) ≤ 0.80 for a major vessel35,37
    • iFR (instantaneous wave-free ratio) ≤ 0.89 for a major vessel35,38,39,40
    • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
  • A major vessel would be a coronary vessel that would be amenable to revascularization, if indicated. This assessment is made based on the diameter of the vessel and/or the extent of myocardial territory served by the vessel.
  • FFR is the distal to proximal pressure ratio across a coronary lesion during maximal hyperemia induced by either intravenous or intracoronary adenosine. Less than or equal to 0.80 is considered a significant reduction in coronary flow.
  • Newer technology that estimates FFR from CCTA images is covered under the separate NIA Guideline for FFR-CT.

Anginal Equivalent1,26,41
Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as D-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope, per se, is not an anginal equivalent.
 
Abbreviations

ACS Acute coronary syndrome
ADLs Activities of daily living
CABG Coronary artery bypass grafting surgery
CAD Coronary artery disease
CCS Coronary calcium score
CCTA Coronary computed tomography angiography
CT(A) Computed tomography (angiography)
COPD Chronic obstructive pulmonary disease
DTS Duke Treadmill Score
ECG Electrocardiogram
EF Ejection fraction
FFR Fractional flow reserve
ICD Implantable cardioverter-defibrillator
iFR Instantaneous wave-free ratio or instant flow reserve
IVUS Intravascular ultrasound
LBBB Left bundle branch block
LVH Left ventricular hypertrophy
MESA Multi-Ethnic Study of Atherosclerosis
METS Metabolic equivalents
MI Myocardial infarction
MPI Myocardial perfusion imaging
PCI Percutaneous coronary intervention
PFT Pulmonary function test
RBBB Right bundle branch block
SE Stress echocardiography
TTE Transthoracic echocardiography
WPW Wolff-Parkinson-White syndrome

References

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Codes

Code Number Description
CPT 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

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 nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2013 Forward     

11/13/2023 Interim review, adding statement regarding electrophysiology testing prior to ablation, Kawasaki/MIS-C section on follow-up and clinical indications not addressed in this policy. Also updating entire policy for consistency

03/07/2023

Annual review, no change to policy intent.

02/21/2023

Interim Review. Updating description, rationale/background, policy and references.

12/07/2022

Annual review, no change to policy

12/02/2021 

Annual review, removing criteria related to low Duke treadmill score, adding high pretest probablility as an alternative to coronary angiography (can also do MPI). Also updating rationale and references. 

10/28/2020 

Annual review, no change to policy intent, updating policy for clarity. Also updating description and references. 

12/02/2019 

Annual review, reformatting entire policy for clarity 

12/17/2018 

Annual review, no change to policy intent. Updating rationale and references. 

12/18/2017 

Annual review, no change to policy intent. Updating background, rationale and references. 

10/31/2016

Annual review, no change to policy intent. Updating background, description, rationale, references and ICD-10 coding.

01/05/2016 

Annual review, no change to policy intent. Adding ICD 10 coding, updating background, description, rationale and references. 

12/01/2014 

Annual review, no change to policy intent. Added coding and policy guidelines. Updated rationale, reference, description, backgrond and regulatory status. 

12/5/2013

Updated policy with additonal description, policy verbiage, rationale and references.

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