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Several types of fast computed tomography (CT) imaging, including electron beam computed tomography (EBCT) 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.
CAC has been recognized to be associated with CAD on the basis of anatomic studies for decades. The development of fast 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 for CAD in patients with subclinical disease, with the goal of instituting appropriate risk-reducing therapy (eg, statin treatment; lifestyle modifications) to improve outcomes. In addition, CAC has been evaluated in patients with symptoms potentially consistent with CAD, but in whom a diagnosis is unclear.
Electron-beam CT (EBCT) (also known as ultrafast CT) and spiral CT (or helical CT) scanning may be used as an alternative to conventional CT scanning due to their faster throughput. Their speed of image acquisition gives them unique value for imaging of the 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 coronary artery calcium, 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 coronary artery disease.
EBCT and multi-detector computed tomography (MDCT) were initially the primary fast CT methods for measurement of coronary artery calcium. A fast CT study for coronary artery calcuim measurement generally takes 10 to 15 minutes and requires only a few seconds of scanning time. More recently, CT angiography has been used to assess coronary calcium. Because of the basic similarity between EBCT and CT angiography in measuring coronary calcium, it is expected that CT angiography provides similar information on coronary calcium as does EBCT.
CT scan‒derived coronary calcium measures have been used to evaluate coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the 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, it could serve as a variable to be used in a risk assessment calculation for the purposes of determining appropriate preventive treatment in asymptomatic patients. Alternatively, in other clinical scenarios, it might help determine whether there is 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 zero 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 actually 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 (CHD) 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 to 400. 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.
Many models of CT devices, including EBCT and other ultrafast CT devices, have been cleared for marketing by FDA through the 510(k) process.
POLICYThe use of computed tomography (CT) to detect coronary artery calcification is considered investigational.
POLICY EXCEPTIONSEffective retroactively to November 17, 1999, and forward, for the Federal Employee Program (FEP) only, Other Medical Benefits may be considered for this procedure based on medical necessity. This procedure is to be considered only for diagnostic services under Other Medical Benefits and is not to be considered as a routine/preventive screening service under Additional Benefits. Under the Blue Cross & Blue Shield Service Benefit Plan, routine services (i.e., services not related to a specific illness, injury, set of symptoms or maternity care) are excluded except for those preventive/routine services specifically described in the Service Benefit Plan brochure.
Effective retroactively to November 17, 1999, and forward, for the Federal Employee Program (FEP) only, plans are to implement this policy immediately. Since there is no specific CPT code for EBCT scanning of the heart, providers may possibly code this service by using 71250, CT scan of the thorax. Claims for EBCT scanning of the heart may be identified by CPT 71250 in conjunction with an ICD-9 Diagnosis Code describing coronary artery disease. (Document #00-081HR)
POLICY GUIDELINESInvestigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY2/1998: Approved by Medical Policy Advisory Committee (MPAC)
5/1999: Reviewed by MPAC; investigational status maintained
11/1999: Reviewed by MPAC; investigational status maintained for all indications
2/2000: Revisions for FEP only
2/8/2002: Investigational definition added
4/26/2002: Type of Service and Place of Service deleted
5/17/2002: Code Reference section completed
6/13/2002: Code Reference section updated
8/7/2002: Sources section updated
2/12/2004: Code Reference section updated, CPT code 76499 deleted
3/25/2004: Reviewed by MPAC, remains investigational, Policy title "Electron Beam Computed Tomography" renamed "Computed Tomography to Detect Coronary Artery Calcification", Description and Policy sections revised to be consistent with BCBSA policy # 6.01.03, Sources updated
5/19/2004: Code Reference section reviewed, no changes
3/13/2006: Coding updated. CPT4 2006 revisions added to policy
3/16/2006: Policy reviewed, no changes
6/29/2006: Code reference section updated, CPT codes 76376 and 76377 deleted. CPT codes 0146T, 0147T, 0148T, 0149T added to non-covered table.
1/30/2007: Code reference section reviewed and updated. CPT codes 0146T and 0148T deleted. CPT code 0144T added
5/15/2007: Policy reviewed, no changes
10/9/2007: Code reference section reviewed; CPT codes 0147T and 0149T removed
7/10/2009: Policy reviewed, no changes
4/20/2010: Coding Section revised for 2010 CPT4 and HCPCS revisions
08/03/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from the Sources section.
09/25/2012: Policy reviewed; no changes.
10/15/2013: Policy reviewed; no changes.
06/18/2014: Policy reviewed; description updated regarding CT angiography. Policy statement revised to change "electron-beam CT or spiral" to "computed tomography" to reflect the scope of the policy; intent unchanged. Removed deleted CPT code 0144T from the Code Reference section.
07/13/2015: Code Reference section updated for ICD-10.
09/25/2015: Policy description updated to add information regarding coronary atherosclerosis and coronary calcium levels. Policy statement unchanged. Investigative definition updated in the Policy Guidelines section.
SOURCE(S)Blue Cross Blue Shield Association policy #6.01.03
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.