Description/Background
A coronary computerized tomography angiogram (CCTA) is a noninvasive imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging computed tomography (CT).^32,33

AUC Score
A reasonable diagnostic or therapeutic procedure care can be defined as that for which the expected clinical benefits outweigh the associated risks, enhancing patient care and health outcomes in a cost-effective manner.¹

• Appropriate Care — Median Score 7 – 9
• May be Appropriate Care — Median Score 4 – 6
• Rarely Appropriate Care — Median Score 1 – 3

Reduction in CCTA test quality

• The following can reduce the quality of the test in patients with:⁸
  • Morbid obesity
  • High or irregular heart rates
  • Severe coronary calcification

Patient Selection Criteria

• Patient selection for CCTA must be considered and may be inappropriate for the following:
  • Known history of severe and/or anaphylactic contrast reaction
  • Inability to cooperate with scan acquisition and/or breath-hold instructions
  • Pregnancy
  • Clinical instability (e.g., acute myocardial infarction, decompensated heart failure, severe hypotension)
  • Renal Impairment as defined by local protocols
  • Image quality depends on keeping HR optimally < 60 bpm (after beta blockers), a regular rhythm, stents > 3.0 mm in diameter, and vessels requiring imaging ≥ 1.5 mm diameter³⁴

General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
INDICATIONS FOR CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY (CCTA)^6,7,8,9
Evaluation in Suspected Coronary Artery Disease (CAD)^{10,11,12,13,14}

Probability

• Low pretest probability patients should be considered for exercise treadmill test (ETT) unless other criteria for CCTA are met⁶
• Intermediate and high pretest probability patients¹⁵
• Exercise ECG stress test with intermediate Duke Treadmill (-10 to +4) 

Asymptomatic Patients

• Asymptomatic patients without known CAD:
  • Previously unevaluated ECG evidence of possible myocardial ischemia including ischemic ST segment or T wave abnormalities (see Uninterpretable baseline ECG section)
  • Previously unevaluated pathologic Q waves (see Uninterpretable baseline ECG section)
  • Previously unevaluated left bundle branch block

Symptomatic Patients

• CCTA is being performed to avoid performing cardiac catheterization in patients with chest pain syndrome with intermediate pretest probability of CAD, uninterpretable ECG and are not able to exercise with no prior CCTA done within the last 12 months who have:^15,16
  • Equivocal, borderline, or discordant stress evaluation with continued symptoms concerning for CAD (AUC 8)⁸
  • Repeat testing in patient with new or worsening symptoms since prior normal stress imaging (AUC 7)⁸
  • Chest pain of uncertain etiology, when non-invasive tests are negative, but symptoms are typical and management requires that significant coronary artery disease be excluded (AUC 7)⁸

Heart Failure

• Newly diagnosed clinical systolic heart failure or diastolic heart failure, with reasonable suspicion of cardiac ischemia unless invasive coronary angiography is planned (SE diversion not required)^17,18 (AUC 7)⁸

Heart Valve

• Before valve surgery or transcatheter intervention as an alternative to coronary angiography^16,19,20
• To establish the etiology of mitral regurgitation²⁰
• Pre-TAVR evaluation as an alternative to coronary angiography^21,22

Heart Anomaly or Aneurysm

• Evaluation of coronary anomaly or aneurysm^{23,24,25,26,27}
  • Evaluation prior to planned repair
  • Evaluation due to change in clinical status and/or new concerning signs or symptoms
  • Kawasaki disease and MIS-C follow-up for medium sized or greater aneurysms²⁸ periodic surveillance can be considered every 2 – 5 years. Once aneurysmal size has reduced to small aneurysms, surveillance can be performed every 3 – 5 years. No further surveillance once normalized.
• Evaluation of suspected pulmonary embolism

NOTE: CMR is favored in younger patients for coronary anomaly evaluation^23,29

PCI or CABG

• Prior PCI or CABG history
  • Symptomatic patient with prior PCI or CABG history, with angina interfering in performing daily activities, despite being on guideline directed medical therapy, and with an equivocal stress test results. No prior CCTA done within the last 12 months (AUC 7)⁸
• Evaluation of coronary artery bypass grafts, to assess:^8,30
  • Patency and location when invasive coronary arteriography was either nondiagnostic or not performed/planned (AUC 7)⁸
  • Location of grafts prior to cardiac or another chest surgery (AUC 7)⁸

Limited Prior or Replacement Imaging

• CCTA may be performed in patients who cannot tolerate moderate sedation that is required during TEE, for pre procedural evaluation for Left Atrial Appendage Occlusion to look for LA/LAA thrombus, spontaneous contrast, LAA morphology and dimensions. TEE however remains the preferred choice of modality for this procedure.

Electrophysiologic Procedure Planning 

• Evaluation of anatomy (pulmonary vein isolation planning) prior to radiofrequency ablation

Rationale
A coronary computerized tomography angiogram (CCTA) is a noninvasive imaging study that uses intravenously administered contrast material and high-resolution, rapid imaging computed tomography (CT)^32,33

AUC Score
A reasonable diagnostic or therapeutic procedure care can be defined as that for which the expected clinical benefits outweigh the associated risks, enhancing patient care and health outcomes in a cost-effective manner.¹

• Appropriate Care — Median Score 7 – 9
• May be Appropriate Care — Median Score 4 – 6
• Rarely Appropriate Care — Median Score 1 – 3

Reduction in CCTA test quality

• The following can reduce the quality of the test in patients with:⁸
  • Morbid obesity
  • High or irregular heart rates
  • Severe coronary calcification

Patient Selection Criteria

• Patient selection for CCTA must be considered and may be inappropriate for the following:
  • Known history of severe and/or anaphylactic contrast reaction
  • Inability to cooperate with scan acquisition and/or breath-hold instructions
  • Pregnancy
  • Clinical instability (e.g., acute myocardial infarction, decompensated heart failure, severe hypotension)
  • Renal Impairment as defined by local protocols
  • Image quality depends on keeping HR optimally < 60 bpm (after beta blockers), a regular rhythm, stents > 3.0 mm in diameter, and vessels requiring imaging ≥ 1.5 mm diameter³⁴

Definitions

• Stable patients without known CAD fall into 2 categories:^6,7,8
  • Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Websites for Global Cardiovascular Risk Calculators section)
  • Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant CA
• Three Types of Chest Pain or Discomfort:
  • Typical Angina (Definite) is defined as including ALL 3 characteristics:
    • Substernal chest pain or discomfort with characteristic quality and duration
    • Provoked by exertion or emotional stress
    • Relieved by rest and/or nitroglycerin
  • Atypical Angina (Probable) has only 2 of the above characteristics
  • Nonanginal Chest Pain/Discomfort has only 0 – 1 of the above characteristics
• The medical record should provide enough detail to establish the type of chest pain. From those details, the pretest probability of significant CAD is estimated from the Diamond Forrester Table below, recognizing that additional coronary risk factors could increase pretest probability:⁸

Diamond Forrester Table^35,36

Very Low: < 5% pretest probability of CAD
Low: 5% – 10% pretest probability of CAD
Intermediate: 10% – 90% pretest probability of CAD
High: > 90% pretest probability of CAD

• An uninterpretable baseline ECG includes:⁶
  • ST segment depression is considered significant when there is 1 mm or more, not for non-specific ST - T wave changes
  • Ischemic-looking T waves are considered significant when there are at least 2.5 mm inversions (excluding V1 and V2)
  • LVH with repolarization abnormalities, WPW, a ventricular paced rhythm, or left bundle branch block
  • Digitalis use with associated ST - T abnormalities
  • Resting HR under 50 bpm on a beta blocker and an anticipated suboptimal workload
  • Note: RBBB with less than 1 mm ST depression at rest may be suitable for ECG treadmill testing
• Previously unevaluated pathologic Q waves (in two contiguous leads) defined as the following: 
  • > 40 ms (1 mm) wide 
  • > 2 mm deep 
  • > 25% of depth of QRS complex
• ECG Stress Test Alone versus Stress Testing with Imaging
  • Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise:⁸
    • The (symptomatic) low pretest probability patient who can exercise and has an interpretable ECG⁸
    • The patient who is under evaluation for exercise-induced arrhythmia
    • The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
    • For the evaluation of syncope or presyncope during exertion³⁷
• Duke Exercise ECG Treadmill Score³⁸
  • Calculates risk from ECG treadmill alone:
    • Duke treadmill score (DTS) equation is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 0 = none, 1 = non-limiting, and 2 = exercise-limiting
    • The score ranges from -25 to +15 with values corresponding to low-risk (score of ≥ +5), intermediate risk (scores ranging from -10 to +4), and high-risk (score of ≤ -11) categories
• Scenarios that can additionally support a CCTA over a regular exercise treadmill test in the low probability scenario³⁹
  • Inability to Exercise
    • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
    • The patient has limited functional capacity (< 4 METS) such as ONE of the following:
      • Unable to take care of their activities of daily living (ADLs) or ambulate
      • Unable to walk 2 blocks on level ground
      • Unable to climb 1 flight of stairs
      • Unable to vacuum, dust, do dishes, sweep, or carry a small grocery bag
  • Other Comorbidities
    • Prior cardiac surgery (coronary artery bypass graft or valvular)
    • Left ventricular ejection fraction ≤ 50%
    • Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
    • Poorly controlled hypertension, with systolic blood pressure (BP) > 180 or Diastolic BP > 120
  • ECG and Echo-Related Baseline Findings
    • Pacemaker or implantable cardioverter defibrillator (ICD)
    • Resting wall motion abnormalities on echocardiography
    • Complete LBBB
  • Risk-Related scenarios
    • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs
    • Arrhythmia risk with exercise
• Global Risk of Cardiovascular Disease
  • Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years.
    • CAD Risk — Low
      • 10-year absolute coronary or cardiovascular risk less than 10%
    • CAD Risk — Moderate
      • 10-year absolute coronary or cardiovascular risk between 10% and 20% 
    • CAD Risk — High
      • 10-year absolute coronary or cardiovascular risk of greater than 20%

Websites for Global Cardiovascular Risk Calculators*^{40,41,42,43,44}

*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.

• Definitions of Coronary Artery Disease^6,7,45,46,47
  • Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).
    • Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. It is not a diagnostic tool so much as it is a risk stratification tool. Its incorporation into global risk can be achieved by using the MESA risk calculator.
    • Stenoses ≥ 70% are considered obstructive coronary artery disease (also referred to as clinically significant), while stenoses ≤ 70% are considered non-obstructive coronary artery disease⁴⁵
    • Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
      • Suggested by percentage diameter stenosis ≥ 70% by angiography; intermediate lesions are 50% – 69%⁸
      • For a left main artery, suggested by a percentage stenosis ≥ 50% or minimum luminal cross-sectional area on IVUS ≤ 6 square mm^6,46,47
      • FFR (fractional flow reserve) ≤ 0.80 for a major vessel^46,47
      • iFR (instantaneous wave-free ratio) ≤ 0.89 for a major vessel^47,48,49,50
      • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
    • A major vessel would be a coronary vessel that would be amenable to revascularization, if indicated. This assessment is made based on the diameter of the vessel and/or the extent of myocardial territory served by the vessel.
    • FFR is the distal to proximal pressure ratio across a coronary lesion during maximal hyperemia induced by either intravenous or intracoronary adenosine. Less than or equal to 0.80 is considered a significant reduction in coronary flow.
    • Newer technology that estimates FFR from CCTA images is covered under the Evolent Clinical Guideline 062-1 for Fractional Flow Reserve CT.
• Anginal Equivalent^6,37,51
  • Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as D-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope, per se, is not an anginal equivalent.

Acronyms/Abbreviations
ACS:    Acute coronary syndrome
ADLs:   Activities of daily living 
CABG:  Coronary artery bypass grafting surgery
CAD:    Coronary artery disease
CCS:    Coronary calcium score
CCTA:  Coronary computed tomography angiography
CT(A):  Computed tomography (angiography)
COPD:  Chronic obstructive pulmonary disease
DTS:     Duke Treadmill Score
ECG:    Electrocardiogram
EF:      Ejection fraction
FFR:    Fractional flow reserve
ICD:     Implantable cardioverter-defibrillator
iFR:     Instantaneous wave-free ratio or instant flow reserve
IVUS:   Intravascular ultrasound
LBBB:   Left bundle branch block
LVH:     Left ventricular hypertrophy
MESA:  Multi-Ethnic Study of Atherosclerosis
METS:  Metabolic equivalents
MI:       Myocardial infarction
MPI:     Myocardial perfusion imaging
PCI:     Percutaneous coronary intervention
PFT:     Pulmonary function test
RBBB:  Right bundle branch block
SE:      Stress echocardiography
TTE:    Transthoracic echocardiography
WPW:  Wolff-Parkinson-White syndrome

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Codes

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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