Summary Of Evidence

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Analysis of Evidence

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Cardiac computed tomographic angiography (CCTA), also known as computed tomography (CT) of the heart and coronary arteries or multidetector computed cardiac tomography (MDCT), is considered reasonable and necessary for the evaluation of suspected symptomatic coronary artery disease (CAD) and for the detection of structural and morphologic intra- and extra-cardiac conditions.

Use of a CCTA is expected to avoid diagnostic cardiac catheterization. If high pre-test probability of CAD exists, this A/B MAC expects the patient to undergo invasive coronary angiography with appropriate percutaneous coronary intervention.

To establish CCTA medical necessity, your case must meet at least 1 indication in the following 2 categories:

Symptomatic (CAD)

1. Evaluation of acute chest pain, unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw pain) when there is:

• Intermediate pre-test probability of CAD* and
• No electrocardiogram (EKG) changes to suggest acute myocardial injury or ischemia and
• Normal initial cardiac markers.
• Patients with intermediate risk and a discordant clinical situation (e.g., ongoing ischemic symptoms, normal stress test).

2. Evaluation of chest pain syndrome when there is:

• Intermediate pre-test probability of CAD* and
• Uninterpretable EKG** or patient is unable to exercise or
• Uninterpretable or equivocal stress test (exercise, perfusion or stress echocardiogram (echo)).

*Intermediate pretest probability of CAD by age, gender and symptoms is between 10% and 90%, as referenced in the American College of Coronary Foundation/American College of Radiology (ACCF/ACR) 2006 appropriateness criteria for cardiac CT and cardiac magnetic resonance imaging (MRI).

** Uninterpretable EKG refers to EKGs with resting ST segment depression greater than or equal to 0.10 mV, complete left bundle branch block, pre-excitation or paced rhythm.

3. Evaluation of intracardiac structures for suspected coronary anomalies.

Suspected Cardiac Structural/Morphologic Anomalies

1. Detection of intracardiac and extracardiac structures in:

• Evaluation of cardiac mass (suspected tumor or thrombus) or
• Evaluation of pericardial conditions (mass, constrictive pericarditis or complications of cardiac surgery) or
• Patients with technically limited images from echo, MRI or transesophageal echocardiography (TEE).

2. Detection of morphologic intracardiac and extracardiac structures for:

• Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation. While data is limited for 3-dimensional (3D) reconstruction of the left atrium for ablations, there is broad consensus among cardiologists that these images, which are integrated and used in real-time in the procedure room to shorten procedure time, improve therapeutic success and enhance patient safety or
• Non-invasive coronary vein mapping prior to placement of biventricular pacemaker or
• Non-invasive coronary arterial mapping, including internal mammary artery, prior to repeat cardiac surgical revascularization or
• Detection of complex congenital heart disease, including anomalies of coronary circulation, great vessels and cardiac chamber and valves or
• Evaluation of coronary arteries in patients with new onset heart failure to assess etiology.

Limitations:

1. Coverage of CCTA is limited to CT devices that process thin, high resolution slices. Decreased resolution and slower rotation speeds result in a higher number of non-evaluable segments. At the current time, Medicare requires the multidetector scanner to have collimation of 0.625 mm or less and a rotational speed of 375 msec or less OR to have at least 64 slice detector design. Do not submit studies from scanners that do not meet these requirements.

2. Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for quantitative evaluation of coronary calcium. This Local Coverage Determination (LCD) does not address Heartflow determinations.

Ultrafast CT scan of the heart electron-beam tomography (EBT) or electron-beam computed tomography (EBCT) is not a covered service.

3. Simultaneous exclusion of obstructive CAD, pulmonary embolism and aortic dissection (“triple rule-out”) in the emergency department is not covered. In order to optimize imaging of the right coronary artery (RCA), contrast must be cleared from the right sided chambers during acquisition, a process that leads to suboptimal contrast timing in the pulmonary arteries. Simultaneous rule-out of aortic pathology (at the low pitch needed to properly image the coronaries) mandates thicker slices in order to capture the total volume required in a reasonable breath hold. The increased slice thickness degrades coronary image quality.

4.  CCTA patients must be able to lie still, follow breathing instructions and take nitroglycerin for coronary dilatation.

5. Prior to the initiation of a CCTA, the physician must make an assessment of the anatomic location, degree and intensity of calcification and impact of the calcification on the utility of the test results.  CCTAs performed on patients with elevated quantitative calcium scores that preclude accurate assessment of coronary anatomy are not covered by Medicare.