Policy Num: 06.001.028
Policy Name: Computed Tomography to Detect Coronary Artery Calcification
Policy ID: [06.001.028] [Ac / L / M+ / P-] [6.01.03]

Computed Tomography to Detect Coronary Artery Calcification

Summary

Description

Several types of fast computed tomography (CT) imaging, including electron-beam CT and spiral CT, allow the quantification of calcium in coronary arteries. Coronary artery calcium (CAC) is associated with coronary artery disease (CAD). The use of CAC scores has been studied in the prediction of future risk of CAD and in the diagnosis of CAD in symptomatic patients.

EBCT software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting coronary artery calcification, both as a diagnostic technique in symptomatic patients to rule out an atherosclerotic etiology of symptoms or, in asymptomatic patients, as an adjunctive method for risk stratification for CAD. This guideline addresses the use of coronary artery calcium (CAC) testing in the outpatient setting

Summary of Evidence

For individuals who are asymptomatic with the risk of coronary artery disease (CAD) who receive coronary artery calcium (CAC) scoring: In an UpToDate review on “Coronary artery calcium scoring (CAC): Overview and clinical utilization” (Kramer) states that “The association between vascular calcification and cardiovascular disease (CVD) is well established. In asymptomatic patients without established atherosclerotic cardiovascular disease (ASCVD), the presence of coronary artery calcification (CAC) on computed tomography (CT) scans is a well-validated measure of subclinical atherosclerosis. The presence of CAC should prompt consideration of aggressive risk factor modification for primary prevention of ASCVD events (including myocardial infarction [MI], stroke, and death from coronary heart disease [CHD]). Advantages of CAC imaging compared with invasive coronary angiography or coronary CT angiography (CCTA) include minimal requirements for patient preparation, no requirement for iodinated intravenous contrast, and relatively low effective radiation doses. Two primary uses of screening for CAC include prediction of atherosclerotic cardiovascular disease (ASCVD) and selection of patients for treatment with aggressive ASCVD risk factor modification (i.e., statin therapy). These suggested uses of CAC scoring, including any therapy based on the results of the CAC scan, are generally in agreement with those of professional societies. CAC scores are usually interpreted in conjunction with other ASCVD risk scoring to guide therapeutic decisions.”

Coronary artery calcium scoring has superior discrimination and risk reclassification as compared with other subclinical imaging markers or biomarkers. In the MultiEthnic Study of Atherosclerosis (MESA) trial, the coronary artery calcium score was strongly associated with 10-year atherosclerotic cardiovascular disease (ASCVD) risk in a graded manner across age, sex, and racial / ethnic groups, independent of traditional risk factors.Coronary artery calcium may even refine ASCVD risk estimates among lower-risk women (<7.5% 10-year risk), younger adults (<45 years of age), and older adults (≥75 years of age), but more data are needed to support its use in these subgroups. A coronary artery calcium score of zero identifies individuals at lower risk of ASCVD events and death over a ≥10-year period, who appear to derive little or no benefit from statins for ASCVD risk reduction.Thus, the absence of coronary artery calcium could reclassify a patient downward into a lower risk group in which preventive interventions (e.g., statins) could be postponed. Note that the absence of coronary artery calcium does not rule out noncalcified plaque, and clinical judgment about risk should prevail. Coronary artery calcium might also be considered in refining risk for selected low-risk adults (<5% 10-year risk), such as those with a strong family history of premature coronary heart disease (CHD). MESA and Astronaut Cardiovascular Health and Risk Modification (Astro-CHARM) are risk estimation tools that incorporate both risk factors and coronary artery calcium for estimating 10-year CHD and ASCVD risk, respectively. Coronary artery calcium measurement is not intended as a “screening” test for all but rather may be used as a decision aid in select adults to facilitate the clinician–patient risk discussion (Arnett, 2019).

A scientific statement was published in October 2006 by the American Heart Association (AHA) Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, Committee on Cardiac Imaging, and Council on Clinical Cardiology. The scientific statement, entitled Assessment of Coronary Artery Disease by Cardiac Computed Tomography, recommended coronary calcium assessment for: patients with chest pain, with equivocal or normal ECG’s, and with negative cardiac enzyme studies; evaluation of symptomatic patients, especially in the setting of equivocal treadmill or functional testing; and measurement of atherosclerosis burden in clinically selected patients at intermediate CAD risk (e.g. those with a 10-20% Framingham 10-year risk assessment), to refine clinical risk prediction and to select patients for more aggressive target values for lipid-lowering therapies. This statement did not recommend coronary calcium assessment to establish the presence of obstructive disease for subsequent revascularization or for serial imaging for assessment of progression of coronary calcification.

The 2010 American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults; IIa Recommendations for Calcium Scoring Methods, stated that measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk). (Level of Evidence: B). The IIb recommendation stated that measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low-to-intermediate risk (6% to 10% 10-year risk). (Level of Evidence: B). No benefit was found for persons at low risk (less than 6% 10-year risk).

In 2018, ACC/AHA Task Force issued a report, jointly supported by multiple professional organizations, entitled Guideline on the Management of Blood Cholesterol. The report recommended the following for intermediate-risk adults or selected borderline-risk adults, in whom a CAC score is measured for the purpose of making a treatment decision: (1) If the CAC score is zero, it is reasonable to withhold statin therapy and reassess in five to 10 years, as long as higher-risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking); (2) If the CAC score is one to 99, it is reasonable to initiate statin therapy for patients greater than or equal to aged 55 years or older and; (3) If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy (Recommendation: IIA).

The American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Primary Prevention of Cardiovascular Disease (2019) recommended that coronary artery calcium measurement can be a useful tool in refining risk assessment for preventive interventions (e.g., statin therapy) for individuals with intermediate predicted risk (greater than or equal to 7.5% to or less than 20%) by the pooled cohort equations (PCE) or for select adults with borderline (5% to <7.5%) predicted risk. In these groups, coronary artery calcium measurement can reclassify risk upward (particularly if coronary artery calcium score is greater than or equal to 100 Agatston units (AU) or greater than or equal to 75th age/sex/race percentile) or downward (if coronary artery calcium is zero) in a considerable proportion of individuals. The extent of reclassification is sufficient to provide confidence that borderline- or intermediate-risk patients with elevated coronary artery calcium will have event rates that clearly exceed benefit thresholds (i.e., greater than or equal to 7.5% in 10 years) and those with coronary artery calcium scores of zero will have event rates less than 7.5%, which can help guide shared decision-making about statins or potentially even aspirin. In the Multi-Ethnic Study of Atherosclerosis (MESA) trial, the coronary artery calcium score was strongly associated with 10-year atherosclerotic cardiovascular disease (ASCVD) risk in a graded manner across age, sex, and racial/ethnic groups, independent of traditional risk factors. Note that the absence of coronary artery calcium does not rule out noncalcified plaque, and clinical judgment about risk should prevail. Coronary artery calcium measurement is not intended as a “screening” test for all, but rather may be used as a decision aid in select adults to facilitate the clinician-patient risk discussion. (Recommendation: IIa; Level of Evidence: B).

The AHA/ACC (2021) Guideline on Evaluation and Diagnosis of Chest Pain includes a recommendation for CAC as first- line testing in patients with stable chest pain with no known coronary artery disease and low likelihood of

obstruction. The guidelines recommend the addition of CAC may also be useful for intermediate-high risk patients with stable chest pain and no known coronary artery disease undergoing stress testing.

Additional Information

Objective

The objective of this evidence review is to evaluate the net health outcome of the use of computed tomography to detect coronary artery calcium in 2 settings:

Policy

Coronary artery calcium (CAC) testing (e.g., electron beam computed tomography (EBCT), ultrafast CT, spiral CT (helical CT) meets the definition of medical necessity for the following indications:

· In the context of shared decision making for members aged 40 to 75 (without clinical atherosclerotic cardiovascular disease), with intermediate-to-low 10-year risk (5 - 20%), with documentation that the coronary artery calcium (CAC) score is necessary to adjust management, such as statin therapy.

· Individuals who are over 75 or younger than 40 years old can be considered for CAC testing when there is documented evidence that the results could alter management:

o Individuals with estimated 10-year risk of less than 5%, but are suspected to be at elevated atherosclerotic cardiovascular disease (ASCVD) risk because of a major risk factor not accounted for in the global risk equations, such as family history of premature coronary artery disease (CAD)

o Individuals in whom statin therapy is indicated but have intolerable adverse effects from statin therapy or are reluctant to take statin medication, in order to guide the need for alternative lipid-lowering strategies

· CAC testing may be repeated for risk re-assessment after a minimum of 5 years, if documentation indicates it will alter management. It should not be repeated if the member already has two CAC scores of zero 5 years apart or has a score ≥ 400.

Policy Guidelines

When quantitative assessment is performed as part of the same encounter as contrast-enhanced cardiac computed tomography (codes 75572-75573) or coronary computed tomography angiography (code 75574), it is included in the service.

The primary fast computed tomography methods for this determination are electron beam computed tomography and multidetector computed tomography.

Coding

Benefit Application

State or federal mandates (eg, Federal Employee Program) may dictate that certain U.S. Food and Drug Administration-approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only by their medical necessity.

Coverage eligibility of computed tomography scanning to detect coronary artery calcium may be limited by contractual exclusions for screening tests.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Coronary artery calcium (CAC) is associated with coronary artery disease (CAD) based anatomic studies. The development of fast computed tomography (CT) scanners has allowed the measurement of CAC in clinical practice. CAC has been evaluated in several clinical settings. The most widely studied indication is for the use of CAC in the prediction of future risk of CAD in patients with the subclinical disease, with the goal of instituting appropriate risk-reducing therapy (eg, statin treatment, lifestyle modifications) to improve outcomes. Also, CAC has been evaluated in patients with symptoms potentially consistent with CAD but in whom a diagnosis is unclear.

Electron-beam computed tomography (EBCT; also known as ultrafast CT) and spiral CT (or helical CT) may be used as an alternative to conventional CT scanning due to faster throughput. In both methods, the speed of image acquisition gives them unique value for imaging a moving heart. The rapid image acquisition time virtually eliminates motion artifact related to cardiac contraction, permitting visualization of the calcium in the epicardial coronary arteries. EBCT software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting CAC, both as a diagnostic technique in symptomatic patients to rule out an atherosclerotic etiology of symptoms or, in asymptomatic patients, as an adjunctive method for risk stratification for CAD.

Electron-beam computed tomography EBCT and multidetector CT were initially the primary fast CT methods for measurement of CAC. A fast CT study for CAC measurement takes 10 to 15 minutes and requires only a few seconds of scanning time. More recently, computed tomography angiography has been used to assess coronary calcium. Because of the basic similarity between EBCT and computed tomography angiography in measuring coronary calcium, it is expected that computed tomography angiography provides information on coronary calcium that is similar to EBCT.

Computed tomography scan-derived coronary calcium measures have been used to evaluate coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but atherosclerosis detected may or may not be causing ischemia or symptoms. Coronary calcium measures may be correlated with the presence of critical coronary stenoses or serve as a measure of the patient's proclivity toward atherosclerosis and future coronary disease. Thus, coronary calcium could serve as a variable to be used in a risk assessment calculation to determine appropriate preventive treatment in asymptomatic patients. Alternatively, in other clinical scenarios, coronary calcium scores might help determine whether there is an atherosclerotic etiology or component to the presenting clinical problem in symptomatic patients, thus helping to direct further workup for the clinical problem. In this second scenario, a calcium score of 0 usually indicates that the patient's clinical problem is unlikely to be due to atherosclerosis and that other etiologies should be more strongly considered. In neither case does the test determine a specific diagnosis. Most clinical studies have examined the use of coronary calcium for its potential use in estimating the risk of future coronary heart disease events.

Coronary calcium levels can be expressed in many ways. The most common method is the Agatston score, which is a weighted summed total of calcified coronary artery area observed on CT. This value can be expressed as an absolute number, commonly ranging from 0 (low-risk) to 400 (high-risk). These values can be translated into age- and sex-specific percentile values. Different imaging methods and protocols will produce different values based on the specific algorithm used to create the score, but the correlation between any two methods appears to be high, and scores from one method can be translated into scores from a different method.

Regulatory Status

Many models of CT devices, including EBCT and other ultrafast CT devices, have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process. Food and Drug Administration product code: JAK.

Rationale

This evidence review was created in December 1995 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through July 11, 2024.

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

The purpose of coronary artery calcium (CAC) scoring using computed tomography (CT) in asymptomatic patients is to assess who may benefit from preventive interventions targeted to minimize the risk of atherosclerotic cardiovascular disease (ASCVD).

The population of interest are individuals who are asymptomatic with risk of CAD.

The intervention of interest is CAC scoring using fast CT imaging, including electron-beam computed tomography (EBCT) and spiral CT in combination with standard risk stratification.

Coronary artery calcium CAC scoring is usually initiated or used to modify cardiac risk-reduction interventions in individuals asymptomatic for CAD and administered in a primary care or general cardiology practice setting.

The following tool is currently being used to make decisions about managing CVD in asymptomatic patients: CAD risk factor stratification based on standard risks, such as the Framingham Risk Score (FRS).

The outcomes of interest include overall survival (OS), test accuracy, test validity, morbid events (eg, major adverse cardiac events [MACEs]), as well as the need for invasive coronary angiography (ICA) and revascularization.

Intermediate or surrogate outcomes of interest are changes in cardiac risk profile indicators such as smoking, hyperlipidemia, or hypertension.

Chain of Evidence

Section Summary: Coronary Artery Calcium Scoring in Asymptomatic Individuals

Multiple observational cohort studies and systematic reviews of these studies have consistently demonstrated the incremental prognostic value of CAC scoring in predicting CVD events compared to standard risk stratification alone among asymptomatic populations over the intermediate and long-term; however, studies have reported mixed findings on whether the use of the score is key to improved cardiovascular outcomes or improvements in other clinical outcomes that lead to cardiovascular risk reduction.

For individuals who are asymptomatic with the risk of CAD who receive CAC scoring, the evidence includes multiple systematic reviews, RCTs, and nonrandomized observational studies. The relevant outcomes are OS, test accuracy and validity, morbid events, and resource utilization. There is extensive evidence on the predictive value of CAC score screening for CVD among asymptomatic patients, and this evidence has demonstrated that scanning has incremental predictive accuracy above traditional risk factor measurement.

Coronary Artery Calcium Scoring in Symptomatic Patients

In certain clinical situations, such as patients presenting with chest pain, it is uncertain whether the symptoms are due to CAD. Coronary calcium measurement has been proposed as a method to rule out CAD in certain patients if their CAC score is 0. The presence of any coronary calcium can be a sensitive but not specific test for coronary disease because CAD rarely occurs in the absence of coronary calcium, False-positives occur because the calcium may not be associated with an ischemic lesion. The absence of any coronary calcium can be a specific test for the absence of coronary disease and direct the diagnostic workup toward other causes of the patient's symptoms. In this context, coronary calcium measurement is not used to make a positive diagnosis but as a diagnostic "filter" to rule out an atherosclerotic cause for the patient's symptoms.

The use of CAC scoring with CT in symptomatic patients can rule out the atherosclerotic etiology of CAD.

The population of interest are individuals who have signs and/or symptoms suggestive of CAD.

The intervention of interest is CAC scoring using fast CT imaging, including EBCT and spiral CT. CAC scoring using CT is administered in a cardiology practice or emergent care setting for patients undergoing evaluation of chest pain. CT CAC scoring is utilized when individuals require evaluation for persistent stable angina or experience onset of acute chest pain.

The following test is currently being used to make decisions about managing CAD: standard diagnostic testing, which includes functional testing and exercise electrocardiography.

The outcomes of interest include OS, test accuracy, test validity, morbid events (eg, MACEs, need for ICA and revascularization).

Section Summary: Coronary Artery Calcium Scoring in Symptomatic Patients

Systematic reviews and meta-analyses have reported a very low negative likelihood ratio for CAC score in predicting MACEs and significant coronary stenosis, suggesting the potential value of a calcium score of 0 in ruling out an atherosclerotic etiology of the disease. However, multiple observational studies with angiographic (CCTA or ICA) interventions have suggested that a CAC score of 0 may not rule out the presence of significant atherosclerotic CAD among symptomatic patients. Currently, evidence from nonrandomized, observational studies has suggested a very low short- or long-term risk of cardiovascular events or death in patients having calcium scores of 0 compared with those having positive (>0) calcium scores. However, considering the inconsistency in evidence regarding the diagnostic accuracy of calcium scoring and lack of evidence from RCTs, further research is needed to examine the clinical utility of ruling out atherosclerotic CAD based on a CAC score of 0.

For individuals with signs and/or symptoms suggestive of CAD who receive CAC scoring before other diagnostic testing, the evidence includes prospective and retrospective nonrandomized studies. The relevant outcomes are OS, test accuracy and validity, morbid events, and resource utilization. CAC scoring has potential as a diagnostic test to rule out CAD in patients presenting with symptoms or as a "gatekeeper" test before invasive imaging is performed. Evidence from observational studies has suggested that negative results on CAC scoring rule out CAD with good reliability.

SUPPLEMENTAL INFORMATION

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

Practice Guideline - American Heart Association/American College of Cardiology

The American College of Cardiology and American Heart Association (2018) Clinical Practice Guidelines on the Management of Blood Cholesterol state, "When risk status is uncertain, a coronary artery calcium (CAC) score is an option to facilitate decision making in adults 40 to 75 years of age."^41, The guidelines further note, "One purpose of CAC scoring is to reclassify risk identification of patients who will potentially benefit from statin therapy. This is especially useful when the clinician and patient are uncertain whether to start a statin. Indeed, the most important recent observation has been the finding that a CAC score of 0 indicates a low ASCVD risk for the subsequent 10 years. Thus, measurement of CAC potentially allows a clinician to withhold statin therapy in patients showing 0 CAC."

With regard to the prognostic significance of CAC, the guideline "makes use of the available data to predict the risk associated with CAC."^41, The guideline notes that "these data need to be amplified by new and ongoing studies to guide treatment decisions" and that "particular uncertainty exists about the predictive value of intermediate CAC scores." Additionally, there are concerns regarding the predictive significance of a CAC score of 0, which must be further verified in follow-up studies. For patients with a 0 score, "it is currently uncertain when and if follow-up CAC measurements should be done to reassess risk status."

The American College of Cardiology and American Heart Association (2019) Guideline on the Primary Prevention of Cardiovascular Disease is in line with the blood cholesterol guideline stating that adults (40 to 75 years of age) who are being evaluated for cardiovascular disease prevention should initially undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation with a clinician-patient risk discussion before starting pharmacological therapy.^42, The guideline also notes that assessing for other risk-enhancing factors can help guide decision making "about preventive interventions in select individuals, as can CAC scanning." The guideline specifically states the following recommendation regarding assessment of cardiovascular risk and CAC:

The American Heart Association, American College of Cardiology (2021) Guideline on Evaluation and Diagnosis of Chest Pain includes a recommendation for CAC as first-line testing in patients with stable chest pain with no known coronary artery disease and low likelihood of obstruction.^43, The guidelines recommend the addition of CAC may also be useful for intermediate-high risk patients with stable chest pain and no known coronary artery disease undergoing stress testing.

Special Report - American Heart Association/American College of Cardiology

The American Heart Association and the American College of Cardiology (2019) issued a special report on the use of risk assessment tools to guide decision-making in the primary prevention of ASCVD.^44, This report includes an algorithm of clinical approaches to incorporate CAC measurement in risk assessment for borderline- and intermediate-risk patients:

"For borderline-risk (10-year risk 5% to <7.5%) and intermediate-risk (7.5% to <20%) patients who are undecided regarding statin therapy, or when there is clinical uncertainty regarding the net benefit, consider the value of additional testing with measurement of CAC. If CAC is measured, interpret results as follows:

a. CAC score of 0 indicates that a borderline- or intermediate-risk individual is reclassified to a 10-y event rate lower than predicted, and below the threshold for benefit from a statin. Consider avoiding or postponing statin therapy unless there is a strong family history of premature ASCVD, history of diabetes mellitus, or heavy cigarette smoking. Consider repeat CAC measurement in 5 years if patient remains at borderline or intermediate risk.

b. CAC score 1 to 99 and <75th percentile for age/sex/race/ethnicity indicates that there is subclinical atherosclerosis present. This may be sufficient information to consider initiating statin therapy, especially in younger individuals, but does not indicate substantial reclassification of the 10-y risk estimate. Consider patient preferences and, if statin decision is postponed, consider repeat CAC scoring in 5 years.

c. CAC score 100 or >75th percentile for age/sex/race/ethnicity indicates that the individual is reclassified to a higher event rate than predicted, that is above the threshold for statin benefit. Statin therapy is more likely to provide benefit for such patients."

National Institute for Health and Care Excellence

For patients with "stable chest pain who cannot be excluded by clinical assessment alone," the National Institute for Health and Care Excellence recommended CT using 64-slice imaging.^45,

MEDICARE NATIONAL COVERAGE

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

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34. Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association cholesterol management guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2015; 66(15):1657-1668.

35. O’Malley PG, Feuerstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavorial change, and cardiovascular risk profile: a randomized controlled trial. JAMA 2003; 289(17): 2215-2223.

36. Pender A, Lloyd-Jones DM, Stone NJ, et al. Refining statin prescribing in lower-risk individuals, informing risk/benefit decisions. J Am Coll Cardiol 2016; 68(15):1690-1697.

37. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). European Heart Journal. 2016; 37:2315– 2381.

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43. LCD L33947 Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

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Codes	Number	Description
CPT	75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
	75572	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
	75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function, and evaluation of venous structures, if performed)
	75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
	0710T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report
	0711T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission
	0712T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability
	0713T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report
HCPCS	S8092	Electron beam computed tomography (also known as ultrafast CT, cine CT)
ICD-10-CM		Investigational for all relevant diagnoses
	I25.10-I25.119	Atherosclerotic heart disease of native coronary artery
	I25.700-I25.799	Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris
	Z13.6	Encounter for screening for cardiovascular disorders
ICD-10-PCS		ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this imaging.
	B221ZZZ, B223ZZZ	Imaging, heart, computed tomography (CT), no contrast (code by body part – coronary arteries, multiple or coronary artery bypass grafts, multiple)
Type of Service	Radiology
Place of Service	Outpatient/inpatient

Date	Action	Description
09/25/25	Annual Review	Policy updated with literature review through September 11, 2025; two references were added (43 & 44) .Policy reviwed and approved at the Physicians Advisory Committee
03/18/25	Replace Policy	Changed to Local Status. Based upon our criteria and assessment of the peer-reviewed literature, CT for coronary calcium scoring for asymptomatic and non -asymptomatic coronary artery disease (CAD) screening is considered medically appropriate for individuals in both populations. References were changed and are aligned with the new policy statement.
10/07/24	Annual Review	Policy updated with literature review through July 11, 2024; no references added. Policy statements unchanged.
10/04/23	Annual Review	Policy updated with literature review through July 27, 2023; no references added. Policy statements unchanged. A paragraph for promotion of greater diversity and inclusion in clinical research of historically marginalized groups was added in Rationale section.
10/05/22	Annual Review	Policy updated with literature review through July 18, 2022; references added. Policy statements unchanged. Codes 0710T-0713T were added.
10/11/21	Annual Review	Policy updated with literature review through July 28, 2021; reference added. Policy statement unchanged
10/20/20	Annual Review	Policy adopted and translated from BCBS EPS. Policy updated with literature review through August 4, 2020; references added. Policy statements unchanged.
09/28/16
05/22/15
06/11/14
08/08/13
06/12/13
01/18/12		(ICD-10 added)
07/07/09		(iCES)
09/24/08
06/22/06