Coverage determination

Verify member benefits and applicable state/federal mandates before determining coverage. The policy states that computed tomography (CT) to detect coronary artery calcification (CAC) is considered experimental/investigational and may be a basis for denial; rely on the member's contract at time of service for final coverage determinations.

• Contact Blue Cross and Blue Shield of Kansas Customer Service to verify benefits prior to ordering.
• State and federal mandates and member contract language take precedence over this policy.

Prior authorization for CT/CAC pathways

No explicit prior authorization requirement or formal prior authorization pathway for CAC is specified in this excerpt. When CT-based diagnostic pathways are used (eg, contrast-enhanced cardiac CT/CCTA), follow any prior authorization rules that apply to those services per the member's plan.

• Prior authorization not specified in this policy excerpt — check the member contract and payer prior auth resources.
• If using a CT-based diagnostic pathway that includes CAC as part of tiered testing (eg, calcium scan followed by CCTA), obtain any required prior authorization for the CT/CCTA service per plan rules.

Procedure codes and medical necessity linkage

Procedure and diagnosis codes listed in the Coding section are informational and are considered medically necessary ONLY if the procedure is performed according to the Policy section. Inclusion of a code here does not guarantee coverage or reimbursement.

• Codes are for billing reference only; verify coverage with the member's contract at time of service.
• Medically necessary status is conditional on meeting the Policy criteria described in this document.

Code listing for cardiac CT services

Providers must submit applicable procedure codes when billing for cardiac CT services. The Coding section lists CPT/HCPCS codes relevant to CAC and cardiac CT; include the appropriate code(s) that reflect the service provided.

• Primary CAC code: 75571 (CT heart without contrast, with quantitative coronary calcium evaluation).
• Cardiac CT / CCTA codes: 75572, 75573, 75574.
• Additional technology/analysis codes listed (0710T–0713T) and EBCT S8092 are included for informational purposes.

Policy coverage stance

Computed tomography (CT) to detect coronary artery calcification is considered experimental / investigational per this policy. Use of CAC scoring may be a basis for denial; always refer to the member's contract to determine coverage for an individual member.

• Policy stance: CT to detect CAC = experimental / investigational.
• Refer to member contract benefits at time of service to determine coverage.

Step therapy not specified

This policy excerpt does not specify step therapy or sequencing restrictions beyond describing tiered testing approaches in trial descriptions. There is no formal step-therapy mandate in this text; limit testing to clinical scenarios supported by the policy and member benefits.

• Step therapy not specified — no enforced sequencing defined in this excerpt.
• Clinical trial descriptions suggest limiting CAC scoring to intermediate-risk subjects in some contexts; apply clinical judgment and payer rules.

Expected testing sequence

Trials and observational studies describe an expected testing sequence in some protocols (eg, CAC scan first, followed by selective CCTA if Agatston score between specified thresholds). Consider these tiered approaches when clinically appropriate and when permitted by plan rules.

• Example from Lubbers et al: CAC scan first; if Agatston score 1–400 then proceed to CCTA; CAC=0 often used to rule out CAD in protocols.
• Clinical use should follow policy criteria and member coverage determinations.

Evidence threshold implication

Evidence threshold considerations in the policy include study selection criteria requiring adequate sample sizes and methodological rigor to inform clinical validity. The policy notes that some studies required a minimum of 1000 patients for inclusion in evaluation of clinical validity.

• Study selection criteria: reported marketed technology version, suitable reference standard, described clinical characteristics and selection criteria, and minimum sample size (≥1000) for evaluation of clinical validity.

Bundling of quantitative assessment

When a quantitative coronary calcium assessment is performed during the same encounter as contrast-enhanced cardiac CT (75572, 75573) or coronary CT angiography (75574), the quantitative assessment is included in the service and should not be billed separately.

• If quantitative CAC assessment is performed during the same visit as contrast-enhanced cardiac CT/CCTA, follow bundling rules — it is included in codes 75572–75574.
• Primary fast CT methods include EBCT and MDCT.

Documentation to support use

Document the clinical indication, primary presenting problem (eg, symptomatic evaluation details, pretest risk), and rationale for ordering CAC or cardiac CT. Maintain records that support medical necessity and adherence to policy criteria.

• Include documentation of symptoms (if present), risk stratification, and how test results will affect management.
• For asymptomatic screening requests, note that policy emphasizes use in specific populations and that CAC scoring is considered investigational by this policy.

Required clinical documentation

Required clinical documentation should include a symptomatic evaluation, pretest probability/risk assessment, and indication for testing. Record relevant findings that justify the selected imaging strategy and support medical necessity under the policy.

• Document symptom status (asymptomatic vs symptomatic), clinical history, and risk factors.
• Specify the intended diagnostic pathway (eg, CAC first, then selective CCTA) and how results will influence care.
• Keep contemporaneous notes to support claims if audited.

Coverage verification required

Coverage verification is required — the code list is informational only and does not guarantee coverage. Always refer to the member's contract and verify benefits at the time of service.

• Coding list may not be comprehensive; use the member contract for coverage determinations.
• Contact BCBSKS Customer Service for benefit verification.

Coding inclusion note

Include quantitative calcium assessment codes in the service record when performed during a contrast-enhanced cardiac CT or coronary CTA encounter; the policy states this assessment is considered part of those services and should follow coding inclusion rules.

• Coding inclusion note: quantitative coronary calcium assessment is included in 75572–75574 when performed in the same encounter.
• Primary methods: EBCT and MDCT.