Local Coverage Determination (LCD)

Cardiac Computed Tomography & Angiography (CCTA)

L33423

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11201 - MAC A	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11301 - MAC A	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11401 - MAC A	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11501 - MAC A	J - M	North Carolina
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

LCD Information

Document Information

LCD ID
L33423

LCD Title
Cardiac Computed Tomography & Angiography (CCTA)

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL33423

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 04/06/2023

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
08/03/2017

Notice Period End Date
09/17/2017

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(1)(D) Investigational or Experimental.

Title XVIII of the Social Security Act, §1862 (a)(7) Excludes routine physical examinations.

42 CFR §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §220.1 Computed Tomography (CT)

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 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.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Contact for Comments on Proposed LCD

Coding Information

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Medical 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 policy.

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

Bibliography

Budoff MJ, Achenbach S, Duerinckx A. Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography. J Am Coll Cardiol. 2003;42(11):1867-1878.
Budoff MJ, Georgiou D, Brody A, et al. Ultrafast computed tomography as a diagnostic modality in the detection of coronary artery disease: A multicenter study. Circulation. 1996;93(5):898-904.
Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.
Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on exercise testing). J Am Coll Cardiol. 2002;40(8):1531-1540.
Hendel RC, Patel MR, Kramer CM, Poon M. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol. 2006;48(7):1475-1497.
Kramer CM, Budoff MJ, Fayad ZA, et al. ACCF/AHA 2007 clinical competence statement on vascular imaging with computed tomography and magnetic resonance: A report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians task force on clinical competence and training. Circulation. 2007;116(11):1318-1335.
Marwick TH, Cain P. Screening for coronary artery disease. Med Clin North Am. 1999;83(6):1375-1402.
O’Malley PG, Feuerstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavioral change, and cardiovascular risk profile: A randomized controlled trial. JAMA. 2003;289(17):2215-2223.
O'Rourke RA, Brundage BH, Froelicher VF, et al. American College of Cardiology/American Heart Association expert consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. J Am Coll Cardiol. 2000;36(1):326-340.
Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol. 2005;46(8):1606-1613.
Ropers D, Baum U, Pohle K, et al. Detection of coronary artery stenoses with thin-slice multi-detector row spiral computed tomography and multiplanar reconstruction. Circulation. 2003;107(5):664-666.
Rybicki FJ, Udelson JE, Peacock WF, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: A joint document of the American College of Radiology appropriateness criteria committee and the American College of Cardiology appropriate use criteria task force. J Am Coll Radiol. 2016;13(2):e1-e29.
Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. Circulation. 2010;122(21):e525-e555.
Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol. 2014;63(4):380-406.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
04/06/2023	R15	Under *CMS National Coverage Policy* updated section headings for regulations. Under *Associated Information* subheading *Utilization Guidelines* removed the verbiage “(Circulation. 2005:112(4):598-617/ J Am Coll Cardiol. 2005:46(2):383-402).” Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD.	Provider Education/Guidance
04/22/2021	R14	Under *CMS National Coverage Policy* corrected the descriptions for the second through fifth regulations in this section. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD where applicable. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/24/2019	R13	This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) A56691 article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/11/2019	R12	All coding located in the *Coding Information* section has been removed and is included in the related Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) A56691 article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/04/2019	R11	Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Typographical Error
08/09/2018	R10	Under *Coverage Indications, Limitations and/or Medical Necessity* typographical errors were corrected and acronyms were defined as appropriate. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Punctuation was corrected throughout the policy as appropriate. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Public Education/Guidance
02/26/2018	R9	The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.	Change in Affiliated Contract Numbers
01/29/2018	R8	The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.	Change in Affiliated Contract Numbers
01/01/2018	R7	Under *CPT/HCPCS Codes* *Group 1* added 0501T, 0502T, 0503T and 0504T. This revision is due to the Annual CPT/HCPCS Code Update. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To CPT/HCPCS Code Changes
10/01/2017	R6	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* ICD-10 code I27.2 was deleted and ICD-10 codes I27.20, I27.21, I27.22, I27.23, I27.24, I27.29, I27.83, I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, and I50.89 were added. The code description was revised for I50.1. Under *ICD-10 Codes That Support Medical Necessity Group 2: Codes* ICD-10 code P29.3 was deleted and ICD-10 code P29.38 was added. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
09/18/2017	R5	Under *Coverage Indications, Limitations and/or Medical Necessity-* Symptomatic Coronary Artery Disease (CAD) added a bullet with the verbiage “Patients with intermediate risk and a discordant clinical situation (e.g. ongoing ischemic symptoms, normal stress test)”. Under Limitations added verbiage in number 2. “This LCD does not address Heartflow determinations”, deleted the verbiage in number 4. “CCTA patients must be able to lie still, follow breathing instructions, take nitroglycerine for coronary dilatation and take a beta-blocker or calcium blocker to achieve heart rates less than 70 BPM” and added the verbiage and the verbiage “CCTA patients must be able to lie still, follow breathing instructions, and take nitroglycerin for coronary dilatation” and deleted the verbiage in number 5. “Prior to the initiation of a CCTA, there must be an imaging assessment of coronary calcification (calcium scoring). The physician must make an assessment of the anatomic location, degree and intensity of calcification and impact of 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” and added the verbiage “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. CCTA’s performed on patients with elevated quantitative calcium scores that preclude accurate assessment of coronary anatomy are not covered by Medicare”. Under *Sources of Information and Basis for Decision* added new citations.	Provider Education/Guidance
03/16/2017	R4	Under CMS National Coverage Policy for Title XVIII of the Social Security Act, §1862(a)(1)(D) revised the verbiage to read “Items and services related to research and experimentation” and for Title XVIII of the Social Security Act, §1862(a)(7) revised the verbiage to read “states Medicare will not cover any services or procedures associated with routine physical checkups”.	Provider Education/Guidance
10/01/2016	R3	Under *ICD-10 Codes That Support Medical Necessity: Group 2 Covered ICD-10 Codes for CPT code 75573* added Q25.21, Q25.29, Q25.40, Q25.41, Q25.42, Q25.43, Q25.44, Q25.45, Q25.46, Q25.47, Q25.48, and Q25.49. Under *ICD-10 Codes That Support Medical Necessity: Group 2* deleted Q25.2 and Q25.4.This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2016.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
02/25/2016	R2	Under *CMS National Coverage Policy* added 42 CFR 410.32. Under *Sources of Information and Basis for Decision* corrected the following journal titles to now read: Kramer CM, Budoff MJ, Fayad ZA, et al. ACCF/AHA 2007 Clinical Competence Statement on Vascular Imaging with Computed Tomography and Magnetic Resonance: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training: developed in collaboration with the Society of Atherosclerosis Imaging and Prevention, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine and Biology. Circulation. 2007;116(11):1318-1335 and Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article. J Am Coll Cardiol. 2002;40(8):1531-40.	Provider Education/Guidance Other
10/01/2015	R1	Under *CMS National Coverage Policy* deleted CMS Internet-Only Manual, Pub 100-04, Medicare Processing Manual, Chapter 18, §§100-100.7 as this relates to billable cardiovascular disease screening CPT codes. Under *Coverage Indications, Limitations and/or Medical Necessity-Limitations 2.* revised the sentence to provide clarification. Under *Coverage Indications, Limitations and/or Medical Necessity-Limitations 3.* added right coronary artery for clarification of the abbreviation RCA. Under *Coverage Indications, Limitations and/or Medical Necessity-Limitations 4.* deleted “For” at the beginning of the sentence. Under *Associated Information-Documentation Requirements* added “the” to the second sentence of the first paragraph. Under *Associated Information-Documentation Requirements* added “s” to “expect” in the second paragraph. Under *Associated Information-Utilization Guidelines* added supplement numbers to the cited journal articles. Under *Sources of Information and Basis for Decision* the titles were corrected for the following: JACC. 2006;48(7):1475-1497 and Circulation. 2007;116(11):1318-1335. The following journal citation was deleted as it was redundant: Hendel R, et al. 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. J Am Coll Cardiol. 2006; 48(7):1476-97. “Et al” was deleted, author names and initials were added and supplement numbers were added to several cited references.	Provider Education/Guidance Typographical Error

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A55670 - (MCD Archive Site)
A56691 - Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA)
LCDs
DL33423 - (MCD Archive Site)

Updated On	Effective Dates	Status
03/27/2023	04/06/2023 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

CCTA
Computed Tomography
Angiography

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Cardiac Computed Tomography & Angiography (CCTA)

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Page Help for LCD - Cardiac Computed Tomography & Angiography (CCTA) (L33423)

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