Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27483

Computed Tomographic Angiography of the Chest

L27483

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Multislice or Multidetector Computed Tomography (MDCT) angiography with its advanced spatial resolution has opened up new possibilities in the imaging of the major vessels of the chest, including aorta, pulmonary arteries, coronary arteries, left subclavian, brachiocephalic and left common carotid artery.

MDCT technology for cardiac assessment requires thin (up to 1 mm) slices, 0.5 to 0.75 mm reconstructions, multiple simultaneous images (e.g. 16 or 32 slices), and cardiac gating (often requiring beta blockers for ideal heart rate). There is significant post processing, depending on the number of slices per second for image generation. For coronary artery imaging, the resulting images show a high correlation with stenotic lesions noted on diagnostic cardiac catheterization but more importantly, with atheromas on intracoronary ultrasound.

Additionally, the technique may be helpful to define the pathology of certain chest or lung parenchymal lesions, which have significant underlying vascularity. For noncardiac assessment, the multidetector scan may be capable of less than 16 slices per second.

Indications

The MDCT angiography of the chest for non-cardiac assessment (71275) is indicated for the following signs or symptoms of disease:

1. Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;
   
2. Abnormalities of extra-cardiac vasculature such as aortic dissection, aortic aneurysm, pulmonary AVM and other abnormalities of the systemic circulation;
   
3. Assessment of suspected congenital anomalies of the great vessels; or
   
4. Assessment of mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.

The MDCT angiography of the heart for cardiac assessment (0146T-0149T, 0151T) is indicated for the following signs or symptoms of disease:

1. Emergency evaluation of acute chest pain;
   
2. Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), as an alternative to cardiac catheterization;
   
3. Management of a symptomatic patient with known coronary artery disease (e.g., post-stent, post CABG);
   
4. Assessment of coronary or pulmonary venous anatomy.
   
5. Assessment of suspected congenital anomalies of coronary circulation;
   
6. Diagnostic evaluation of a patient with current uninterpretable or equivocal stress imaging test results; or
   
7. In lieu of routine invasive coronary angiography prior to non-coronary cardiac or aortic surgery in patients at low risk of concomitant coronary disease.

Additionally, in the instance of emergency evaluation of acute chest pain, it may be necessary to evaluate the patient for both cardiac and noncardiac disease (e.g., pulmonary embolus or aortic dissection and coronary artery occlusive disease). The typical acquisition and post-processing protocols used for pulmonary embolus or aortic dissection will not supply the needed information for exclusion of coronary artery occlusive disease. To obtain this additional information, additional acquisition and post-processing algorithms are used in addition to those employed for the 71275 examination; therefore, in the emergency evaluation of acute chest pain, when evaluation of the aorta, pulmonary vasculature and coronary circulation is ordered and performed, CPT^® codes 0146T-0149T, 0151T may be reported in addition to CPT^® code 71275. In this instance there must be 2 separate evaluations/reports to support both services.

Limitations

1. The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
   
2. The selection of the test must be made within the context of other testing modalities so that the resulting information facilitates the management decision, not merely adds a new layer of testing.
   
3. The test will be denied, on post-pay review, as not medically necessary when used for cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive calcification that would diminish the interpretive value.
   
4. Coverage of this modality for coronary artery assessment is limited to devices that process thin, high resolution slices (1 mm or less). The multidetector scanner must have at least 16 slices per second capability. For non-cardiac assessment, the multidetector scan may have a capability of less than 16 slices per second.
   
5. The administration of beta-blockers and the monitoring of the patient by a cardiologist during the MDCT are not separately payable services.
   
6. A physician or a qualified non-physician practitioner must order all MDCT studies.
   
7. A physician or qualified non-physician provider must be present during testing.
   
8. The electron beam tomography (EBT) technology is not addressed in this LCD.

Diagnostic Tests, X-Rays

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned.

The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, an interpretive report and copies of images. The computerized data with image reconstruction should also be maintained.

Documentation must be available to Medicare upon request.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Who is a candidate for non invasive Coronary Angiograpy (Editorial).  Philip Greenland, MD.  Annals of Internal Medicine (Sept 2006). 2006; 145:466-467

Coronary CT angiography.  Hoffmann V, Ferencik M, Cury RC, Pena AJ. J Nuclear Med, 2006 May; 47(5):797-806.

New Imaging Techniques for diagnosing coronary artery disease.  Escolar E, Weigold G, Fuisz A, Weissman NJ.  Medstar Research Institute, Medstar Health, Washington Hosp Center.  CMAJ, 2006 Feb 17; 174(4):487-95.

Coronary CT angiography with 64-MDCT:  Assessment of Vessel Visibility.  Pannu HK, Jacobs JE, Lai S, Fishman

Cardiac Multidector – row computed Tomography in patients with unstable angina.  Dirken MS, et al. AM Journal Cardiology. 2005 Feb 15; 95(4):457-61.

Integrated Approaches to Evaluating Coronary Artery Disease and Ischemic Heart Disease by Richard D. White, MD, and Randolph M. Setser, DSc, The American Journal of Cardiology, Vol 90 (10C), November 21, 2002.

Clinical Utility of Computed Tomography and Magnetic Resonance Techniques for Noninvasive Coronary Angiography by Matthew J. Budoff, MD, Stephen Achenbach, MD, Andre Duerinckx, MD, Torrance, California; Dallas, Texas; and Erlangen, Germany. The Journal American Coll of Cardiology, Vol 42, No. 11, December 2003.

Detection of Coronary Artery Stenoses With Thin-Slice Multi-Detector Row Spiral computed Tomography and Multiplanar Reconstruction by Dieter Ropers, MD; Ulrich Baum, MD; Karsten Pohle, MD; Kathrina Anders, MD; Stefan Ulzheimer, PhD; Bernd Ohnesorge, PhD; Christian Schlundt, MD; Werner Bautz, MD; Werner G. Daniel, MD; Stephan Achenbach, MD. Circulation Journal, February 11, 2003.

Noninvasive Assessment of Coronary Artery Disease by Multislice Spiral Computed Tomography Using a New Retrospectively ECG-Gated Image Reconstruction Technique – Comparison With Angiopgraphic Results by Uichi Sato, MD; Naoya Matsumoto, MD; Masahiko Kato, MD; Fumio Inoue, MD; Toshiyuki Horie, MD; Junji Kusama, MD; Akihiro Yoshimura, MD; Takako Imzeki, MD; Takahiro Fukui, DM; Satoru Furuhashi, MD; Motoichiro Takahashi, MD; Katsuo Kammatsuse, MD. Circulation Journal, Vol.67, May 2003.

Detection of Coronary Artery Stenoses by Contrast-Enhanced, Retrospectively Electrocardiographically-Gated, Multislice Spiral Computed Tomograhy by Stephan Achenbach, MD; Tom Giesler, MD; Dieter Ropers, MD; Stefan Ulzheimer, MS; Hans Derlien; Christoph Schulte, MD; Evelyn Wenkel, MD; Werner Moshage, MD; Werner Bautz, MD; Werner G. Daniel, MD; Willi A. Kalender, PhD; Ulrich Baum, MD. Circulation Journal, May 29, 2001.

Non-Invasive Coronary Angiography with High Resolution Multidetector-row Computed Tomography by A. F. Kopp, S. Schroeder, A. Kuettner, A. Baumbach, C. Georg, R. Juzo, M. Heuschmid, B. Ohnesorge, K. R. Karsch and C. D. Claussen, The European Society of Cardiology, Published by Elsevier Science Ltd. in the European Heart Journal (2002)23, 1714-1725.

Non-invasive Characterisation of Coronary Lesion Morphology by Multislice Computed Tomography: a promising new technology for risk stratificaiton of patient with coronary artery disease by Stepehn Schroeder, Andreas F. Kopp, Angreas Baumbach, Axel Kuettner, Christian Georg, Bernd Ohnesorge, Christian Herdeg, Claus D. Claussen, Karl R Karsch. @ http://heart.bmjjournals.com.

3D Assessment of myocardial Perfusion Parameter Combined with 3D Reconstructed coronary Artery Tree from Digital Coronary Angiogram,s by T.H. Schindler, N. Magosaki, M. Jeserich, E. Nitzsche, U. Oser, T. Abdollahnia, M.Nageleisen, M. Zehender, H. Just & Y, Solzbah. International Journal of Cardiac Imaging 16: 1-12, 2000.

Aortoiliac and Renal Arteries: Prospective Intraindividual comparison of Contrast-enhanced Three-dimentional MR Angiography and Multi-Detector Row CT angiography, by J. K. Willmann, MD, S. Wildermuth, MD, T. Pfammatter, MD, J. E. Roos, MD, B. Seifert, PhD, P. R. Hilfiker, MD, B. Marincek, MD, D. Weishaupt, MD. Radiology, Volume 226, Number 3, pages 798-811.

Multi-Slice CT Angiography in Diagnosing Total Versus Near Occlusions of the Internal Carotid Artery – Comparison With Catheter Angiography, by Chi-Jen Chen, MD, Tsong-Hai Lee, MD, PhD, Hui-Ling Hsu, MD, Ying-Chi Tseng, MD, Shinn-Kuang Lin, MD, Li-Jen Wang, MD, Yon-Cheong Wong, MD. Stroke available at http://strokeaha.org

Detection of Plaque Instability Predictors by Multislice Computed Tomography, Comparison with Intravascular Ultrasound, study by P. M. Carrascosa, Sr., Carlos Capunay, Sr., Peter Johnson, Sr., Pablo Garcia Merletti, Sr., Raul Pissiis, Sr., Jorge Manuel Carrascosa, Sr., Diagnostico Maipu, Buenos Aires, Argentina, Presentation March 7, 2004, American College of Cardiology, National Scientific Sessions.

Non-Invasive Assessment of In-Stent Restenosis by 16-Slice Computed Tomography, study by O. Kuboyama, T. Kakuta, S. Kimura, T. Yonestsu, K. Susuki, Y. Nagata, M. Goya, Y. Lesaka, H. Fujiwara, M. Isobe, Tsuchiura Kyodo Hospital, Tsuchiura, Japan. Presentation March 9, 2004, American College of Cardiology, National Scientific Sessions.

Comparison of Retrospectively Electorcariogram-Gated, Multislice spiral Computed Tomography and Selective Coronary angiography in the analysis of Stent Permeability after Left Main or Ostial Coronary Artery Angioplasty, study by E. Maupas, D. Carrie, M. Elbaz, M. Bennaceur, H. Rousseau, F. Joffre, J. Puel, Rangueil Hospital, Toulouse, France. Presentation March 7, 2004, American College of Cardiology, National Scientific Sessions.

Comparison of 16-Slice Submillimeter Multidetector Spiral Computed Tomography with Conventional Angiography for Diagnosis of Coronary Artery Disease, study by D. F. Bush, J. M. Miller, J. C. Lima, E. P, Shapiro, John Hopkins Bayview Medical Center, Baltimore, MD. Presentation March 7, 2004, American College of Cardiology, National Scientific Sessions.

ACC, ACR, ASNC, NASCI, SCAI, and SCCT Model LCD

Other Contractor’s Policies:   Highmark Medicare Services Pennsylvania Carrier, Palmetto GBA Fiscal Intermediary

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27483

07/31/2008

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