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.