|6.01.03||Computed Tomography to Detect Coronary Artery Calcification|
|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/5:2014
|Return to Medical Policy Index|
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Electron-beam computed tomography (CT; also known as ultrafast CT) uses an electron gun rather than a standard x-ray tube to generate x-rays, thus permitting very rapid scanning. Spiral CT scanning (also referred to as helical CT scanning) also creates images at greater speeds by rotating a standard x-ray tube around the patient such that data are gathered in a continuous spiral or helix rather than in individual slices.
While both electron-beam CT (EBCT) and spiral computed tomography (CT) scanning may be valued as an alternative to conventional CT scanning due to their faster throughput, their speed of image acquisition also permits unique imaging of the moving heart. For example, 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 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 coronary artery disease.
EBCT and multi-detector computed tomography (MDCT) were initially the primary fast CT methods for measurement of coronary artery calcification. A fast CT study for coronary artery calcium 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.
The use of computed tomography (CT) to detect coronary artery calcification is considered investigational.
Effective in 2010, there is a category I CPT code for this imaging:
75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
When quantitative assessment is performed as part of the same encounter as contrast-enhanced cardiac CT (codes 75572-75573) or coronary CT angiography (code 75574), it is included in the service.
Prior to 2010, there was a category III CPT code specific to CT scanning of the heart to detect coronary artery calcification:
0144T Computed tomography, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium.
In addition, there were 2 category III CPT codes for CT angiography with quantitative evaluation of coronary calcium – 0147T and 0149T. These codes were discontinued 12/31/09.
The primary fast CT methods for this determination are electron-beam computed tomography (EBCT) and multi-detector computed tomography (MDCT).
BlueCard/National Account Issues
Coverage eligibility of computed tomography (CT) scanning to detect coronary artery calcification may be limited by contractual exclusions for screening tests.
State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved devices may only be assessed on the basis of their medical necessity.
This policy was created in December 1995 and updated periodically with literature review. The most recent update covers the period through April 14, 2014.
The rationale for measuring calcium in coronary arteries is that it measures coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not be causing ischemia or symptoms. Such a measure 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 (CAD) 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 computed tomography (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 2 methods appears to be high, and scores from 1 method can be translated into scores from a different method.
This policy is based, in part on a 1998 TEC Assessment.(1)
Coronary calcium for coronary disease risk stratification
Many prospective studies have shown evidence for predictive capacity of calcium scores in addition to assessment of traditional risk factors for coronary heart disease (CHD) among asymptomatic subjects. In a study of 1029 asymptomatic adults with at least 1 coronary risk factor, Greenland et al(2) showed that a calcium score of greater than 300 predicted increased risk of cardiac events within Framingham risk categories. A study by Arad et al(3) showed similar findings in a population-based sample of 1293 subjects who had both traditional risk factors and calcium scores evaluated at baseline. A study by Taylor et al(4) studied the association of the Framingham risk score and calcium scores in a young military population (mean age, 43 years). Although only 9 acute coronary events occurred, calcium scores were associated with risk of events while controlling for the risk score. LaMonte et al(5) also analyzed the association of calcium scores and CHD events in 10,746 adults. In this study, coronary risk factors were self-reported. During a mean follow-up of 3.5 years, 81 CHD events occurred. Similar to the other studies, the relationship between calcium scores and CHD events remained after adjustment for other risk factors. Budoff et al evaluated the association of coronary calcium scores and CHD events during 5 years of follow-up in an analysis of 2232 adults from the Multiethnic Study of Atherosclerosis (MESA), a prospective cohort study to evaluate cardiac risk factors and 3119 subjects from the Heinz Nixdorf RECALL (HNR; Risk factors, Evaluation of Coronary Calcium and Lifestyle Factors) study.(6) Increasing Agatston score was associated with increased risk of CHD: in the MESA study compared with a CAC score of 0, having a score greater than 400 was associated with a hazard ratio (HR) for CHD of 3.31 (95% confidence interval [CI], 1.12 to 9.8) after adjusting for CHD risk factors; a score of 100-399 was associated with an HR of 3.27 (95% CI, 1.19 to 8.95). In the HNR study, the HR for CHD was 2.96 (95% CI, 1.22 to 7.19). Lower CAC scores were not significantly associated with CHD after adjustment for other risk factors. Other studies(7-10) show similar findings.
Additional studies have defined how the incorporation of calcium scores into risk scores changes risk prediction. In a study by Polonsky et al,(11) incorporation of calcium score into a risk model resulted in more subjects (77% vs 66%) being classified in either high-risk or low-risk categories. The subjects who were reclassified to high risk had similar risk of CHD events as those who were originally classified as high risk. A study by Elias-Smale et al(12) showed similar findings; reclassification of subjects occurred most substantially in the intermediate-risk group (5%-10% 5-year risk) where 56% of persons were reclassified.
Numerous studies have also evaluated the predictive ability of coronary calcium using CT angiography.(13-16) These studies have included different populations, such as patients with or without risk factors or patients with an intermediate risk of CAD. Similar to studies that use external beam computed tomography (EBCT), these studies have demonstrated that calcium scores derived from CT angiography provide incremental predictive information for the overall risk of CAD, as compared with coronary angiography and for the future occurrence of major cardiac events.
Multiple prospective studies have found that CAC scoring is associated with future risk of CHD events. CAC scores likely add to the predictive ability of clinical risk prediction models. However, studies enrolled different populations, assessed different traditional risk factors, and assessed different coronary disease outcomes. Different calcium score cutoffs were analyzed in the studies. Given the variation in the studies, the magnitude of increased risk conferred by a given calcium score is still uncertain.
Impact on cardiac risk factor profiles in practice
While epidemiologic studies suggest that CAC scoring may be associated with future CHD risk, this does not, by itself, demonstrate that the use of CAC scoring improves clinical outcomes.
There have been a small number of RCTs of the impact of EBCT on cardiac risk factors. In 2012, Whelton et al published a meta-analysis of RCTs that evaluated the impact of coronary calcium scores on cardiac risk profiles and cardiac procedures.(17) There were 4 trials identified with a total of 2490 participants; theindividual trials ranged in size from 50 to 1934 patients. The authors pooled data from 4 trials on the impact of calcium scores on blood pressure, 3 on the impact on low-density lipoprotein, and 2 on the impact on high-density lipoprotein. Pooled analysis did not show a significant change in any of these parameters as a result of calcium scores. Similarly, in 4 studies that looked at the rates of smoking cessation following calcium scores, there was not significant change found. There were 2 studies that included rates of coronary angiography and 2 studies that included rates of revascularization. Pooled analysis of these studies did not show a significant change following measurement of coronary calcium.
Two RCTs representative of this evidence are discussed further here. O’Malley et al(18) randomized 450 subjects to receive EBCT or not and assessed outcomes 1 year later for change in Framingham Risk Score. Thus, EBCT was to be used as a guide to refine risk in patients and possibly provide motivation for behavioral change. The study was not powered for clinical end points. EBCT did not produce any benefits in terms of a difference in Framingham risk score at 1 year.
An RCT was published in 2011 evaluating the impact of CT scanning for CAC on cardiac risk factors.(19) A total of 2137 healthy subjects were randomized to CT scanning or no CT scanning and followed for 4 years. At baseline, both groups received 1 session of risk factor counseling by a nurse practitioner. The primary outcome was change in 12 different cardiac risk profile measures, including blood pressure, lipid
and glucose levels, weight, exercise, and the Framingham risk score. At the 4-year follow-up, there was differential dropout among the groups, with 88.2% of follow-up in the scan group versus 81.9% in the no-scan group. Results demonstrated differences in 4 of the 12 risk factor measurements between groups: systolic blood pressure, low-density lipoprotein, waist circumference, and mean Framingham risk score.
This trial highlights the potential benefit of CAC screening in modifying cardiac risk profile but is not definitive in demonstrating improved outcomes. Limitations of this study include different intensity of interventions between groups and differential dropout. It is possible that the small differences reported in the trial were the result of bias from these methodologic limitations. In addition, this trial does not compare
the impact of other types of risk factor intervention, most notably more intensive risk factor counseling. Finally, the generalizability of the findings is uncertain given that this was a volunteer population that may have been highly motivated for change.
Johnson et al reported results from a descriptive prospective study to assess the association between CAC score and subsequent health behavior change.(20) The study included a convenience sample of 174 adults with CHD risk factors who underwent CAC scoring. The authors found no significant change in risk perception measured by the Perception of Risk of Heart Disease Scale scores between groups (CAC score 0, 1-10, 11-100, 101-400, >400), with the exception of a small increase in the moderate-risk group (CAC score, 101-400) from 55.5 to 58.7 (p=0.004). All groups demonstrated increases in health-promoting behavior over time.
Studies that use CAC scoring in asymptomatic patients have reported mixed findings about whether CAC testing leads to improved cardiovascular risk profiles or improvements in other meaningful clinical outcomes. The largest meta-analysis did not find significant improvements in cardiac risk profiles or use of cardiac procedures with the use of CAC scoring.
Coronary calcium for ruling out atherosclerotic etiology of disease in symptomatic patients
In certain clinical situations, such as patients presenting with chest pain or other symptoms, it is uncertain whether the symptoms are potentially due to CHD. Coronary calcium measurement has been proposed as a method that can rule out CHD in certain patients if the coronary calcium value is zero. Because coronary disease can only very rarely occur in the absence of coronary calcium, the presence of any
coronary calcium can be a sensitive but not specific test for coronary disease. False positives occur because the calcium may not be causing ischemia or symptoms. 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 of any kind but as a diagnostic “filter” used to rule out an atherosclerotic cause for the patient’s symptoms.
For example, Yerramasu et al reported results of a prospective study to assess an evaluation algorithm including CAC scoring for patients presenting to a rapid access chest pain clinic with stable chest pain possibly consistent with CHD.(21) Three hundred patients presenting with acute chest pain to 1 of 3 chest pain clinics underwent CAC scoring. If the CAC score was 1000 or more Agatston units invasive coronary
angiography was performed, and if the CAC score was less than 1000, coronary CT angiography (CCTA) was performed. All patients with a CAC of zero and low pretest likelihood of CHD had no obstructive CHS on CCTA and were event-free during follow up. Of the 18 patients with CAC score from 400 to 1000, 17 (94%) had greater than 50% obstruction on subsequent CCTA and were referred for further evaluation, 14 (78%) of whom had obstructive CHD. Of 15 patients with CAC score 1000 or more and who were referred for coronary angiography, obstructive CHD was present in 13 (87%). This study suggests that CAC can be used in the acute chest pain setting to stratify decision making for further testing.
In a study by Laudon et al in the emergency department setting, 51% (133/263) patients with chest pain and low-to-moderate probability of CAD had calcium scores of zero.(22) One of these patients was found to actually have coronary disease. The others were presumed to not have coronary disease, and it is claimed that these patients could have been safely discharged from the emergency department. However, the study is not rigorous in its methods regarding the alternative workup of potential CAD in the emergency department or in the long-term follow-up of patients.
In addition to studies that use coronary calcium scores to rule out CHD among patients presenting with symptoms potentially consistent with CHD, coronary calcium scoring has also been evaluated to rule in or out potential CHD in symptomatic patients before invasive coronary angiography or stress nuclear imaging. The 2007 expert consensus guidelines from the American College of Cardiology and the American Heart association state that CAC may serve “as a filter prior to invasive coronary angiography or stress nuclear imaging” but that “prognostic studies of CAC in symptomatic patients have generally been limited by biased samples (eg, patients referred for invasive coronary angiography) and small numbers of hard outcome events.”
Since the 2007 consensus statement, several studies have addressed the use of CAC scoring as part of a management strategy for patients presenting with symptoms possibly consistent with CHD. In 2014, Hulten et al published results from a retrospective cohort study among symptomatic patients without a history of CHD to evaluate the accuracy of CAC for excluding coronary stenosis among symptomatic patients, using CCTA as the criterion standard.(23) The study included 1145 patients who had symptoms possibly consistent with CHD who underwent a noncontrast CAC score and a contrast enhanced CCTA from 2004 to 2011. For detection of greater than 50% stenosis, CAC had a sensitivity of 98% and specificity of 55%, corresponding to a negative predictive value of 99%. For prediction of cardiovascular death or myocardial infarction, the addition of either or both CAC or CCTA to a clinical prediction score did not significantly increase prognostic value.
ten Kate et al conducted a prospective study to evaluate the accuracy of cardiac CT, including CAC scoring with or without CCTA, in distinguishing heart failure due to CAD from heart failure due to non- CAD causes.(24) Data on the predictive ability of a negative CAC in ruling out CAD was also included. The study included 93 symptomatic patients with newly diagnosed heart failure of unknown etiology, all of whom underwent CAC scoring. Those with a CAC score of greater than 0 underwent CCTA, and if the CCTA was positive for CAD (>20% luminal diameter narrowing), invasive coronary angiography was recommended. Forty-six percent of patients had a CAC score of zero. At follow-up of mean duration 20 months, no patient with a CAC score of zero had a myocardial infarction, underwent percutaneous coronary intervention, had a coronary artery bypass graft, or had signs of CAD.
Dharampal et al retrospectively evaluated a cohort of 1975 symptomatic patients who underwent clinical evaluation and CAC scoring and CCTA or invasive coronary angiography (ICA).(25) The primary outcome was obstructive CAD (≥50% stenosis) on ICA or CCTA (if ICA was not done). The authors evaluated the net reclassification improvement with the addition of CAC score to a clinical prediction model for patients
who had an intermediate probability of CHD (10%-90%) after clinical evaluation based on chest pain characteristic, age, gender, risk factors, and electrocardiogram. Discrimination of CAD was significantly improved by adding the CAC score to the clinical evaluation (area under the curve, 0.80 vs 0.89, p<0.001).
A number of studies suggest that CAC scoring could be used to rule in or rule out CHD, particularly regarding decisions about further invasive imaging. However, relatively few studies have employed a prospective design. Further studies need to be conducted to address some of the potential barriers to such an approach, including whether performing CAC scoring in symptomatic patients delays diagnosis or intervention and whether the net effect of CAC scoring is to increase or decrease invasive testing.
Future research needs
The current research mainly establishes that CAC screening improves risk prediction for CAD. The 2011 Rozanski et al RCT suggests that scanning may favorably impact cardiac risk profiles but is not sufficient in itself to demonstrate improved outcomes. To demonstrate that use of calcium scores improves the efficiency or accuracy of the diagnostic workup of symptomatic patients, rigorous studies that define exactly how coronary calcium scores are used in combination with other tests in the triage of patients would be necessary. Study designs need to explicitly evaluate diagnostic strategies that compare 1 strategy that uses calcium scores, to an alternative that does not use calcium scores. Ideally, patient outcomes and resource utilization would need to be prospectively evaluated.
Clinical Input Received Through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received through 2 physician specialty societies and 4 academic medical centers on this policy (the version approved in July 2008) in November 2008. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. Most of those providing input agreed with the conclusions of this policy (investigational) as approved in July 2008.
Clinical input received in 2011 was mixed regarding the investigational status of CAC screening. Input was received from 7 sources, 5 academic medical centers, and 2 specialty societies. Four of the 7 reviewers agreed with the investigational status, while 3 dissented. The dissenters primarily cited evidence on the accuracy of scanning for risk prediction of CAD. The American College of Cardiology also cited the 2011 RCT as evidence of the impact of scanning on risk factor profile.
Ongoing Clinical Trials
A search of the online database ClinicalTrials.gov identified the following studies that are evaluating outcomes after interventions using CAC measurements:
Individualized Comprehensive Atherosclerosis Risk-reduction Evaluation Program (iCARE) (NCT00969865) – This study will prospectively evaluate differences in heart disease-related risk factors between patients receiving usual care and those receiving blood tests for markers of heart disease, DNA and RNA analysis, and CAC scanning, in addition to usual care. Enrollment is planned for 670 patients; the planned study completion date is July 2014.
There is extensive evidence on the predictive value of coronary artery calcium (CAC) score screening for cardiovascular disease among asymptomatic patients, and this evidence demonstrates that scanning has incremental predictive accuracy above traditional risk factor measurement. However, evidence from high-quality studies that demonstrate that the use of CAC score measurement in clinical practice leads to changes in patient management or in individual risk behaviors that improve cardiac outcomes is lacking.
CAC scoring has a potential role as a diagnostic test to rule out coronary artery disease (CAD) in patients presenting with symptoms or as a “gatekeeper” test before invasive imaging is performed. Evidence from retrospective studies suggests that negative results on CAC scoring rules out CAD with good reliability. However, further prospective trials would be needed to demonstrate that such a strategy is effective in
practice and is at least as effective as alternate strategies for ruling out CAD.
Because of the lack of high-quality evidence demonstrating improved outcomes from either the use of CAC score as a screening test to risk stratify patients or as a diagnostic test to in symptomatic patients, the use of CAC scoring is considered investigational.
Practice Guidelines and Position Statements
In 2006, the American Heart Association (AHA) issued a scientific statement(26) on the use of cardiac CT. Most of the document reviewed the utility of calcium scoring for the use of determining prognosis and diagnosis. In addition to reviewing a large body of evidence regarding calcium scoring, clinical recommendations were also offered. No indications received a class I recommendation, ie, evidence and/or agreement that the procedure is useful and effective. Several indications received a class IIb recommendation, which means that there is conflicting evidence and/or a divergence of opinion regarding usefulness or efficacy. The “b” qualifier indicates usefulness/efficacy is less well established.
Class IIb recommendations:
Patients with chest pain with equivocal or normal ECGs and negative cardiac enzymes
Determining the etiology of cardiomyopathy
Symptomatic patients, in the setting of equivocal treadmill or functional tests
Asymptomatic patients with intermediate (eg, 10%-20% 10-year risk) risk of CAD
Class III recommendations refers to evidence that the procedure or treatment is not useful or possibly harmful.
Low-risk (<10% 10-year risk) and high-risk (>20% 10-year risk) asymptomatic patients
Establishing the presence of obstructive disease for revascularization in asymptomatic persons
Serial imaging for assessment of progression of coronary calcification
Hybrid nuclear and CT imaging
A 2007 clinical consensus document cowritten by the American College of Cardiology Foundation (ACCF) and the AHA(27) reviewed much of the same evidence as the 2006 AHA scientific statement. It should be noted that this type of consensus document represents the best attempt of the ACCF and AHA to inform clinical practice where rigorous evidence is not yet available. Thus formal grading of evidence and classification of clinical recommendations are not reported in this type of document. This document essentially concludes that the indications receiving an IIb recommendation in the 2006 scientific statement “may be reasonable.” Recommendations from the 2010 ACCF/AHA Guidelines are noted next.
In 2009, the U.S. Preventive Services Task Force (USPSTF) issued recommendations regarding the use of nontraditional or novel risk factors in assessing CHD risk in asymptomatic persons.(28,29) Calcium score was 1 of 9 risk factors considered in the report. They concluded that the current evidence is insufficient to assess the balance of benefits and harms of using any of the nontraditional risk factors studied to assess risk of coronary disease in asymptomatic persons. In their focused review of 5 studies, which they judged to have valid study designs, they found wide variation in the estimates of the risk ratio for higher calcium scores. Higher quality studies had lower relative risks for a given difference in calcium score. This review disagrees with the ACCF/AHA 2007 clinical consensus document(27) regarding the effect of calcium scores on reclassifying risk of coronary disease. Rather than the 4 studies that the ACCF/AHA document claims provides information about reclassification, the USPSTF report only finds 1 such study.
In 2010, the ACC/AHA released recommendations on calcium scoring as part of their guidelines on the management of cardiovascular risk in asymptomatic patients.(30) These recommendations include the following:
Class IIa recommendation: 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)
Class IIb recommendation: 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)
Class III recommendation: No Benefit. Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment. (Level of Evidence: B)
In 2012, the ACC/AHA released guidelines for the diagnosis and management of patients with stable ischemic heart disease that include some recommendations related to CAC scoring.(31)
Class IIb recommendation: For patients with a low to intermediate pretest probability of obstructive IHD, noncontrast cardiac computed tomography to determine the coronary artery calcium score may be considered. (Level of Evidence: C)
A systematic review by Ferket et al(32) identified 14 guidelines that evaluated diagnostic imaging for asymptomatic CAD, which included those previously reviewed, and additional guidelines from New Zealand and Canada. Ten of the guidelines addressed use of calcium score as a method to improve coronary risk assessment. Four guidelines concluded that there was sufficient evidence for consideration of its use, and 1 guideline recommended for its use. The only group of patients for whom its use was recommended was that of intermediate-risk patients. For subjects at low risk or high risk, guidelines were unanimous in not advocating calcium scoring.
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Diagnosis and screening for coronary artery disease with electron beam computed tomography. TEC Assessments 1998; Volume 13, Tab 27.
- Greenland P, LaBree L, Azen SP et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. Jama 2004; 291(2):210-5.
- Arad Y, Goodman KJ, Roth M et al. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study; 2005(46):1-Jan// 158-65.
- Taylor AJ, Bindeman J, Feuerstein I et al. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol 2005; 46(5):807-14.
- LaMonte MJ, FitzGerald SJ, Church TS et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol 2005; 162(5):421-9.
- Budoff MJ, Mohlenkamp S, McClelland R et al. A comparison of outcomes with coronary artery calcium scanning in unselected populations: the Multi-Ethnic Study of Atherosclerosis (MESA) and Heinz Nixdorf RECALL study (HNR). J Cardiovasc Comput Tomogr 2013; 7(3):182-91.
- Budoff MJ, Shaw LJ, Liu ST et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007; 49(18):1860-70.
- Elkeles RS, Godsland IF, Feher MD et al. Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study. Eur Heart J 2008; 29(18):2244-51.
- Lakoski SG, Greenland P, Wong ND et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as "low risk" based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med 2007; 167(22):2437-42.
- Martin SS, Blaha MJ, Blankstein R et al. Dyslipidemia, coronary artery calcium, and incident atherosclerotic cardiovascular disease: implications for statin therapy from the multi-ethnic study of atherosclerosis. Circulation 2014; 129(1):77-86.
- Polonsky TS, McClelland RL, Jorgensen NW et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. Jama 2010; 303(16):1610-6.
- Elias-Smale SE, Wieberdink RG, Odink AE et al. Burden of atherosclerosis improves the prediction of coronary heart disease but not cerebrovascular events: the Rotterdam Study. Eur Heart J 2011; 32(16-Jan):2050-8.
- Hou ZH, Lu B, Gao Y et al. Prognostic value of coronary CT angiography and calcium score for major adverse cardiac events in outpatients. JACC. Cardiovascular imaging 2012; 5(10):990-9.
- Meyer M, Henzler T, Fink C et al. Impact of coronary calcium score on the prevalence of coronary artery stenosis on dual source CT coronary angiography in caucasian patients with an intermediate risk. Academic radiology 2012; 19(11):1316-23.
- Bischoff B, Kantert C, Meyer T et al. Cardiovascular risk assessment based on the quantification of coronary calcium in contrast-enhanced coronary computed tomography angiography. European heart journal cardiovascular Imaging 2012; 13(6):468-75.
- Petretta M, Daniele S, Acampa W et al. Prognostic value of coronary artery calcium score and coronary CT angiography in patients with intermediate risk of coronary artery disease. The international journal of cardiovascular imaging 2012; 28(6):1547-56.
- Whelton SP, Nasir K, Blaha MJ et al. Coronary artery calcium and primary prevention risk assessment: what is the evidence? An updated meta-analysis on patient and physician behavior. Circ Cardiovasc Qual Outcomes 2012; 5(4):601-7.
- 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):2215-23.
- Rozanski A, Gransar H, Shaw LJ et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing. J Am Coll Cardiol 2011; 57(15):1622-32.
- Johnson JE, Gulanick M, Penckofer S et al. Does Knowledge of Coronary Artery Calcium Affect Cardiovascular Risk Perception, Likelihood of Taking Action, and Health-Promoting Behavior Change? J Cardiovasc Nurs 2014.
- Yerramasu A, Lahiri A, Venuraju S et al. Diagnostic role of coronary calcium scoring in the rapid access chest pain clinic: prospective evaluation of NICE guidance. Eur Heart J Cardiovasc Imaging 2014.
- Laudon DA, Behrenbeck TR, Wood CM et al. Computed tomographic coronary artery calcium assessment for evaluating chest pain in the emergency department: long-term outcome of a prospective blind study. Mayo Clin Proc 2010; 85(4):314-22.
- Hulten E, Bittencourt MS, Ghoshhajra B et al. Incremental prognostic value of coronary artery calcium score versus CT angiography among symptomatic patients without known coronary artery disease. Atherosclerosis 2014; 233(1):190-5.
- ten Kate GJ, Caliskan K, Dedic A et al. Computed tomography coronary imaging as a gatekeeper for invasive coronary angiography in patients with newly diagnosed heart failure of unknown aetiology. Eur J Heart Fail 2013; 15(9):1028-34.
- Dharampal AS, Rossi A, Dedic A et al. Restriction of the referral of patients with stable angina for CT coronary angiography by clinical evaluation and calcium score: impact on clinical decision making. Eur Radiol 2013; 23(10):2676-86.
- Budoff MJ, Achenbach S, Blumenthal RS et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006;114(16):1761-91. Available online at http //circ.ahajournals.org/cgi/content/full/114/16/61. Last
accessed July 2011.
- Greenland P, Bonow RO, Brundage BH et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007; 49(3):378-402.
- Helfand M, Buckley DI, Freeman M et al. Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the U.S Preventive Services Task Force. Ann Intern Med 2009; 151(7):496-507.
- US Preventive Services Task Force. Using nontraditional risk factors in coronary heart disease risk assessment: U.S Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151(7):474-82.
- 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. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56(22):1864-94.
- Fihn SD, Gardin JM, Abrams J et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012; 60(24):e44-e164.
- Ferket BS, Genders TS, Colkesen EB et al. Systematic review of guidelines on imaging of asymptomatic coronary artery disease. J Am Coll Cardiol 2011; 57(15):1591-600.
|CPT||75571||CT of heart without contrast and quantitative ecaluation of coronary calcium|
|75572||CT of heart with contrast for evaluation of cardiac structure and morphology (including 3D post-processing)|
|75573||CT of heart with contrast for evaluation of cardiac structure and morphology (including 3D post-processing); for congenital heart disease|
|75574||CT angiography with contrast of the heart, coronary arteries and any coronary bypass grafts (including 3D post-processing)|
|ICD-9 Diagnosis||414.00||Coronary atherosclerosis of unspecified vessel|
|414.01||Coronary atherosclerosis of native coronary artery|
|V81.0||Special screening for cardiovascular, respiratory, and genitourniary diseases; ischemic heart disease|
|HCPCS||S8092||Electron beam computed tomography (also known as ultrafast CT, cine CT)|
|ICD-10-CM (effective 10/1/15)||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 (effective 10/1/15)||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|
Cine Computed X-ray Tomography (See Electron Beam CT)
Computed X-ray Tomography (See Electron Beam CT)
Electron Beam Computed Tomography (CT) for Imaging of Coronary Artery Disease
High-Speed Rapid Acquisition X-ray Computed Tomography (See Electron Beam CT)
Ultrafast CT (See Electron Beam CT)
|12/01/95||Add to Radiology section||New Policy|
|07/31/97||Replace policy||Reviewed without changes|
|01/27/99||Replace policy||Policy reviewed and unchanged; Added reference to TEC Assessment|
|08/15/01||Replace policy||Policy reviewed: information on spiral CT scanning added|
|04/29/03||Replace policy||Policy updated; no change in policy statement, references added|
|12/14/05||Replace policy||Literature search done, policy updated; no change in policy statement, references added. CPT coding updated|
|04/17/07||Replace policy||Policy updated with literature search, no change in policy statement. Reference numbers 7 and 8 added. ICD-9 diagnosis coding updated.|
|07/10/08||Replace policy||Poliyc updated with literature search, reference numbers 9 and 10 added. Policy statement unchaged|
|07/09/09||Replace policy||Policy updated with literature search; reference numbers 7, 12, and 13 added. Policy statement unchanged|
|12/29/09||Coding update only||added 75571, 75572, 75573, 75574|
|7/14/11||Replace policy||Policy updated with literature search. Rationale extensively revised and condensed. References 9, 12, 14-16 added; other references removed. No change in policy statement|
|07/12/12||Replace policy||Policy updated with literature search. References 9, 10, 18, 19 added. No change in policy statement|
|6/13/13||Replace policy||Policy updated with literature search through June 2013; references 11-14, 17. No change in policy statement.|
|12/12/13||Replace policy- correction only||In Rationale text discussion of reference 16, text corrected from Seamus et al to Whelton et al.|
|5/22/14||Relplace policy||Policy updated with literature review through April 14, 2014. References 6, 11, 21-22, 24-25, and 31-32 added. Editorial changes made to Rationale, Summary, and Guidelines sections. No change in policy statement.|