Note to my self and my readers: This Medicare Coverage Rule is an outstanding summary of when CT Coronary Angiography is appropriate.
Today, I review, link to, and excerpt from Medicare Coverage rules LCD L33423 Cardiac Computed Tomography & Angiography (CCTA).
All that follows is from the above resource.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
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: A. Symptomatic (CAD) and/or B. Suspected Cardiac Structural/Morphologic Anomalies:A. Symptomatic (CAD)
1. Evaluation of acute chest pain, unexplained dyspnea or symptoms suggesting angina pectoris (such as jaw pain) when there is:
a. Intermediate pre-test probability of CAD* and
No electrocardiogram (EKG) changes to suggest acute myocardial injury or ischemia and
Normal initial cardiac markers.
OR
b. 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, sex 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.
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.
Summary of Evidence
N/AAnalysis of Evidence (Rationale for Determination)N/A
General Information
Associated Information
Documentation RequirementsMedical record documentation should be legible, relevant and sufficient to justify services billed. This documentation should be maintained in the patient’s medical record and must be made available to the A/B MAC upon request.When patient records are requested, this A/B MAC expects the cardiac CT angiogram to be performed for indications listed in this LCD.Utilization Guidelines
This A/B MAC expects that CCTA is performed under the direct supervision of a physician with appropriate training in CT coronary angiography and cardiac CT imaging equivalent to guidelines set forth by the American College of Cardiology (ACC) or ACR.
Sources of Information
N/A
