National Imaging Associates, Inc. Clinical guideline: CT CORONARY ANGIOGRAPHY (CCTA) CPT Codes: 75574 Guideline Number: NIA_CG_062 Responsible Department: Clinical Operations

Original Date: Page 1 of 11 Last Reviewed Date: Last Revised Date: Implementation Date:

October 6, 2009 September 2014 March 2015 March 2015

INTRODUCTION: Coronary computed tomographic angiography (CCTA) is a noninvasive imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging CT equipment to obtain detailed volumetric images of blood vessels. CTA can image blood vessels throughout the body. However, imaging of the coronary vasculature requires shorter image acquisition times to avoid blurring from the motion of the beating heart. The advanced spatial and temporal resolution features of these CT scanning systems offer a unique method for imaging the coronary arteries and the heart in motion, and for detecting arterial calcification that contributes to coronary artery disease. The table below correlates and matches the clinical indications with the Appropriate Use Score based on a scale of 4 to 9, where the upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach. The mid-range (4 to 6) indicates uncertainty in the appropriateness of the test for the clinical scenario. In all cases, additional factors should be taken into account including but not limited to cost of test, impact of the image on clinical decision making when combined with clinical judgment and risks, such as radiation exposure and contrast adverse effects, should be considered. Where the CCTA is the preferred test based upon the indication the Appropriate Use Score will be in the upper range such as noted with indication # 46, Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2010 APPROPRIATE USE SCORE CRITERIA for CCTA: ACCF et al. Criteria # CCTA (Indication and Appropriate Use Score)

(*Refer to Additional Information section)

1 U(5)

Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic Nonacute Symptoms Possibly Representing an Ischemic Equivalent • Low pretest probability of CAD* • ECG interpretable and able to exercise

1 A(7)

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1— CCTA 2015

INDICATIONS

Intermediate pretest probability of CAD* ECG interpretable AND able to exercise

Proprietary

ACCF et al. Criteria # CCTA (Indication and Appropriate Use Score)

INDICATIONS (*Refer to Additional Information section)

2 A(7)

• •

Low pretest probability of CAD* ECG uninterpretable or unable to exercise

2 A(8)

• •

Intermediate pretest probability of CAD* ECG uninterpretable or unable to exercise

2 U(4)

• •

High pretest probability of CAD* ECG uninterpretable or unable to exercise

4 U(6) 5 U(6)

6 Low/Int Risk* A(7) High Risk* U(4) 7 Low/Int Risk* A(7) High Risk* U(4) 8 Low/Int Risk* A(7) High Risk* U(4)

9 A(7) 10 Int Risk** A(7) High Risk** U(4)

Acute Symptoms With Suspicion of ACS (Urgent Presentation) • Persistent ECG ST-segment elevation following exclusion of MI Acute chest pain of uncertain cause (differential diagnosis includes pulmonary embolism, aortic dissection, and ACS ["triple rule out"]) Pretest Probability of CAD • Non-acute symptoms Possibly Representing an Ischemic Equivalent • Normal ECG and cardiac biomarkers (troponin and CPK/CPK-MB) • Non-acute symptoms Possibly Representing an Ischemic Equivalent • ECG uninterpretable • Non-acute symptoms Possibly Representing an Ischemic Equivalent • Nondiagnostic ECG or equivocal cardiac biomarkers Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD Noncontrast CT for CCS • Low global CHD risk estimate** • Family history of premature CHD • Risk assessment in Asymptomatic Patients • No known CAD •

Coronary CTA 11 High Risk** U(4)

• •

12 U(6)

•

Asymptomatic No known CAD Coronary CTA Following Heart Transplantation Routine evaluation of coronary arteries Detection of CAD in Other Clinical Scenarios

13

2— CCTA 2015

New-Onset or Newly Diagnosed Clinical HF and No Prior CAD • Reduced left ventricular ejection fraction (5 years ago

26 U(6)

•

26 A(8)

• •

Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients Coronary Calcium Score 401–>1000 Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients Coronary Calcium Score