Fractional Flow Reserve CT - CAM 175

History of FFR: Fractional Flow Reserve (FFR) is the ratio of baseline coronary flow to coronary flow during maximal hyperemia. Its use in the cardiac catheterization laboratory has successfully demonstrated utility in the quantitation of intracoronary flow dynamics secondary to lesional and microvasculature conditions. This technology has proven helpful in evaluating individual patients, with respect to prognostication of coronary artery disease and with decisions regarding the appropriateness of coronary revascularization. (A caveat is discussed in the Additional Information.)

Adaptation to CCTA: Fractional Flow Reserve using Coronary Computed Tomography Angiography (FFR-CT) is a new technology that seeks to provide an estimation of FFR by non-invasive methodology. Following assessment of quality CCTA images, in the appropriate subsets of patients with coronary stenoses, the technology makes mathematical assumptions to simulate maximal hyperemia, and calculates an estimation of FFR (fractional flow reserve) for those coronary vessels with lesions, based upon the principles of fluid mechanics inherent to the Navier-Stokes Theorem. 

Effort to reduce unnecessary ICA: Since conventional FFR measurement has been performed in conjunction with invasive coronary arteriography (ICA), FFR-CT has been developed with the intention of noninvasively adding hemodynamic information to the anatomic findings on CCTA, with the purpose of safely reducing the frequency of unnecessary ICA procedures (defined as all ICA lesions < 50%). Such a reduction in ICA by FFR-CT has been suggested, but not rigorously proven, by the clinical trials to date. (A caveat is discussed in the Additional Information.) 

Current Methodology: The analysis requires a CCTA with at least a 64-slice capability and good-quality images. At present, the process involves transmitting the CCTA data to an off-site location, where a digital model of coronary anatomy is constructed, and using the CCTA data, FFR is calculated using the above described computational fluid dynamics. In this fashion, a report of estimated FFR for the vessels in question is generated, with the intention of reporting coronary hemodynamic information to the requesting clinician.

The purpose of FFR-CT is to determine if an invasive cardiac catheterization (ICA) can be avoided. All requirements for MEDICALLY NECESSITY below must be met:

  1. The patient was selected for evaluation with coronary computed tomography angiography (CCTA) as a non-invasive test for significant coronary artery disease:
    • Is stable, and
    • Has a pre-test probability of significant, ischemia-producing coronary artery disease between 20% and 50% (low to moderate probability) based on a reliable calculator prior to the CCTA, and
    • The CCTA result demonstrates lesions ≥ 50% OR
  2. The patient was selected for evaluation with CCTA as a non-invasive test for significant coronary artery disease:
    • Is stable, and
    • Has a pre-test probability of significant, ischemia-producing coronary artery disease between 51% and 80% (moderate to high moderate probability based on a reliable calculator prior to CCTA, and
    • The  CCTA result demonstrates lesions between 30% and 50% 
  3. None of the following clinical scenarios apply since FFR-CT has not been adequately validated due to inapplicability of computational dynamics, artifacts, and/or clinical circumstances; These indications will be considered NOT MEDICALLY NECESSARY:
    • Suspicion of, or current presentation of, an acute coronary syndrome, unless the patient has unstable angina, myocardial infarction was excluded, and ICA would not be recommended if FFR-CT were negative
    • Known ischemic coronary artery disease that has not been revascularized, and there has been no change in patient status or in the CCTA images
    • Recent myocardial infarction within 30 days
    • Prior coronary artery bypass graft surgery
    • Patients who require 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 <90 mmHg, severe congestive heart failure (New York Heart Association [NYHA] III or IV) or acute pulmonary edema
    • Complex congenital heart disease or VSD with Qp/Qs > 1.4
    • BMI > 35
    • Metallic stents in the coronary system
    • Coronary vessels with extensive or heavy calcification
    • Coronary lesions needing evaluation in which vessel diameter < 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.

FFR-CT Results:
Quantitative estimation of coronary lesional hemodynamic severity using FFR-CT may enable deferral of invasive coronary arteriography when values are above 0.80.

A decision to follow through with coronary revascularization should not be based upon FFR-CT. Thus, justification for percutaneous coronary intervention should usually require additional invasive FFR or other corroborative non-invasive or angiographic data. FFR-CT data to date provides no evidence showing outcomes comparable to outcomes based upon invasive FFR determinations. By virtue of the assumption of maximal hyperemia, the microvasculature’s true behavior is not actually measured by FFR-CT. This is important, since a coronary lesional intervention will not improve flow if the microvasculature will not allow further increase in flow.

Because of the lack of long-term outcomes data and flaws in the design of multiple trials, and given the controversy evidenced by numerous editorials in peer-reviewed journals, there is a lack of formal guidelines from professional societies at this time. Based upon findings in the PLATFORM trial, patients who are evaluated initially by CCTA with contingent FFR-CT, could be perceived as actually having a higher rate of unnecessary ICA. This has necessitated numerous considerations based upon multiple published trials and meta-analyses in formulating this de novo guideline.

Calculations of pre- and post-test probability:
Prior to each non-invasive test, there is a pretest probability of finding significant coronary artery disease. The result of a non-invasive test yields a post-test probability, which then becomes the pretest probability for a subsequent non-invasive test. This is helpful when a patient who had a prior stress test is being considered for FFR-CT.

    1. University of Washington pretest and post-test probability table (preferred), to determine a pretest probability for patients undergoing FFR-CT subsequent to a prior non-invasive test. The University of Washington Calculator for Pre- and Post-test Probability can be found at this address: 
    2. Updated Diamond Forrester Pretest Probability Table, based upon symptoms prior to initial non-invasive testing:
  Men   Women
Age (years) Non-specific chest pain Atypical chest pain Typical chest pain   Non-specific chest pain Atypical chest pain Typical chest pain
30 – 39 17.7 28.9 59.1   5.3 9.6 27.5
40 – 49 24.8 38.4 68.9   8.0 14.0 36.7
50 – 59 33.6 48.9 77.3   11.7 20.0 47.1
60 – 69 467 59.4 83.9   16.9 27.7 57.7

The source of the tables above can be found at

  1. 3.  European Society of Cardiology CAD Consortium Pretest Probability, based upon clinical information (CAC optional) prior to non-invasive testing for coronary artery disease. The ESC CAD Consortium Pretest Probability Calculator can be found at this address:

CCTA = Coronary Computerized Tomographic Angiography
CIED = Cardiac Implanted Electrical Devices
ESC = European Society of Cardiology
FFR = Fractional Flow Reserve
ICA = Invasive Coronary Arteriography
MACE = Major Adverse Coronary Events
NPV = Negative Predictive Value


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  2. BL Norgaard, J Hjort, S Gaur, et al. Clinical Use of Coronary CTA–Derived FFR for Decision-Making in Stable CAD. JACC Cardiovascular Imaging, Vol 10, No5, 2017, p 5451-550.
  3. BL Nørgaard, J Leipsic, S Gaur, et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol. Apr 1 2014; 63(12):1145-1155. PMID 24486266.
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  11. IM Graham. Diagnosing coronary artery disease—the Diamond and Forrester model revisited. Eur Heart J. 2011 Jun;32(11):1311-2. doi: 10.1093/eurheartj/ehr015. Epub 2011 Mar 11.
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  13. JK. Min. Look Backwards But Live Forwards JACC Cardiovasc Imaging. 2017 May;10(5):551-553. doi: 10.1016/j.jcmg.2015.12.014
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  19. National Institute for Health and Care Excellence. HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography
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Coding Section 

Code Number Description
CPT 0501T Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
  0502T Data preparation and transmission
  0503T Analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model
  0504T Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

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.

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