Currentblue cross blue shield - kansasPolicy N/A

Coronary Artery Calcification (CAC) Scoring with CT

This policy governs the use of computed tomography to detect coronary artery calcification (CAC) for evaluation and risk stratification of coronary artery disease in BCBSKS members.

Policy Summary

Payerblue cross blue shield - kansas

PolicyCoronary Artery Calcification (CAC) Scoring with CT

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 14, 2008

Next Review DateOct 28, 2025

Key ActionVerify member benefits and document clinical indication before ordering; CAC scoring is designated experimental/investigational per this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

510(k) - JAKFDA product code for CT devices used for CAC

≥1,000Minimum sample size for diagnostic studies

96%Sensitivity of CAC=0 for future events (pooled)

HR 6.57Risk (CAC>100 vs 0)

up to 19%0 CAC with ≥50% stenosis reported

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Coverage Criteria

General Coverage

Overall policy stance: The use of computed tomography (CT) to detect coronary artery calcification (CAC) is considered experimental/investigational.

Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage for an individual member.

Contexts supported by evidence

Contexts where CAC scoring may be clinically useful based on available evidence:

Intermediate-risk primary prevention: CAC scoring adds predictive information and improves risk reclassification most consistently when applied to asymptomatic patients at intermediate baseline cardiovascular risk (eg, analyses from MESA and other cohort studies).intermediate pretest risk

Observational cohorts demonstrate reclassification and improved discrimination in intermediate-risk groups.

Shared decision-making for preventive therapy: CAC ≥100 identifies higher-risk individuals more likely to benefit from preventive interventions (eg, aspirin or lipid-lowering therapy), whereas CAC=0 identifies patients with low event rates where therapy may be deprioritized.CAC ≥100 vs 0

Cohort analyses (eg, Cainzos-Achirica, Budoff) support use of CAC to inform selection for preventive pharmacotherapy.

Behavioral and risk-factor modification: Disclosure of CAC results can increase initiation or adherence to statins and some lifestyle changes, though randomized trials show mixed effects and no demonstrated reductions in cardiovascular events or mortality to date.N/A

Systematic reviews and RCTs report improved risk factors and medication initiation but no consistent effect on hard outcomes.

Diagnostic use in symptomatic individuals

Covered when ALL of the following are met for symptomatic evaluation

Symptomatic CAD evaluation preconditions: Individual has signs and/or symptoms suggestive of coronary artery disease (eg, persistent stable angina or acute chest pain) and the clinician intends to use CAC scoring as part of the diagnostic evaluation.

Population of interest defined by symptomatic presentation.

Planned diagnostic pathway: CAC scoring is performed using CT (eg, EBCT or multidetector/spiral CT) with a pre-specified, tiered protocol that documents conditional coronary CT angiography (CCTA) if the Agatston score falls within protocol-defined ranges (for example, initial calcium scan followed by CCTA when Agatston 1–400).Agatston-based tiered protocol (eg, 1–400)

Reflects trial protocols where CAC guided selective CCTA (eg, Lubbers et al).

Intended management linkage: There is a documented plan for how CAC results will affect immediate diagnostic management (eg, rule out atherosclerotic etiology if CAC=0; proceed to CCTA or further testing per protocol when CAC>0).

Evidence-based stance

Evidence summary and implications

Clinical validity and utility summary: Systematic reviews and meta-analyses report a very low negative likelihood ratio for CAC score (particularly CAC=0) in predicting major adverse cardiovascular events and significant coronary stenosis, suggesting CAC=0 may help rule out an atherosclerotic etiology. However, multiple observational studies have also reported that CAC=0 does not reliably exclude obstructive CAD in symptomatic patients; clinical validity in symptomatic populations is inconsistent and randomized trial evidence of clinical utility is lacking. Consequently, a complete chain of evidence demonstrating improved patient-relevant outcomes from use of CAC scoring in symptomatic patients cannot be constructed.

Further research, including RCTs demonstrating impact on clinical outcomes, is needed to establish clinical utility.

The policy designates the use of computed tomography (CT) to detect coronary artery calcification (CAC) as experimental/investigational. Coverage for CAC scoring is therefore excluded under this policy language, and final coverage determination for an individual member depends on the member's contract benefits in effect at the time of service.

Systematic reviews and meta-analyses of CAC screening in asymptomatic adults report improvements in some intermediate measures—such as initiation or adherence to preventive medications, modest improvements in lipids, and some self-reported lifestyle changes—but no included studies reported reductions in cardiovascular events or all-cause mortality after screening.

The evidence threshold for establishing clinical utility requires demonstration of clinical validity in studies that meet methodological criteria (including a suitable reference standard and adequate sample size). The policy notes that eligible diagnostic validity studies should report on the marketed technology, describe patient selection and characteristics, include a reference standard, and generally meet a minimum sample size (eg, ≥ 1,000 in selection criteria). If these clinical validity criteria are not met, inferences about clinical utility cannot be made and the use may not be supported.

Because systematic reviews and meta-analyses report inconsistent diagnostic accuracy—especially regarding whether a CAC score of 0 reliably excludes significant atherosclerotic CAD in symptomatic patients—and randomized controlled trial evidence on clinical outcomes is lacking, further research is needed. Clinicians should be cautious: a CAC score of 0 may lower the probability of an atherosclerotic cause but should not be assumed to definitively rule out disease without corroborating clinical assessment or follow-up testing where indicated.

Historically, the Coding section of this policy included a Diagnosis subsection stating: "Experimental/Investigational for all diagnoses related to this policy." This wording was added in prior revisions to align coding guidance with the policy's experimental/investigational stance.

Routine CAC screening of asymptomatic adults without a clinical indication or outside contexts where results would directly inform management decisions is not supported by evidence of improved clinical endpoints. Systematic reviews and pooled trial data do not demonstrate reductions in cardiovascular events or mortality for routine population screening.

Randomized trials that evaluated EBCT/CAC disclosure as a motivational intervention or to drive short‑term changes in calculated risk (eg, Framingham Risk Score) generally did not demonstrate meaningful benefit at 1 year. For example, an RCT assessing EBCT as a motivational tool in an asymptomatic population found no significant change in 10‑year Framingham Risk Score at 1 year. Thus, use of EBCT/CAC solely as a motivational tool or to change short‑term risk profiles is not supported by the cited RCT evidence.

Coding and Code Definitions

Regulatory device codemixed

JAK	FDA product code for CT devices used to detect coronary artery calcification

No CPT/HCPCS/ICD codes in this excerptmixed

No codes listed

Procedure Codes (Informational)CPT | HCPCS

75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
75572	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed).
75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function, and evaluation of vascular structures, if performed).
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing.
0710T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report.
0711T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission.
0712T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability.
0713T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report.
S8092	Electron beam computed tomography (also known as ultrafast CT, cine CT).

Covered CPT/HCPCS CodesCPT/HCPCS

75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
75572	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed).
75573	Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function, and evaluation of vascular structures, if performed).
75574	Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).
0710T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report.
0711T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission.
0712T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability.
0713T	Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report.
S8092	Electron beam computed tomography (also known as ultrafast CT, cine CT).

Agatston score risk tiers

Agatston score range0 (low risk) to 400+ (high risk)

Score interpretationExpressed as absolute number and convertible to age- and sex-specific percentiles

Typical reporting ceilingValues commonly described up to 400 in categorical risk tiers; higher absolute values also reported

CAC score categories

Common CAC categories0; 1–100; >100; ≥400

Clinical interpretation (per guidelines/cohorts)0 = no detectable calcium; 1–100 = mild; >100 = moderate–high; ≥400 = very high

Use in reclassificationCategories used in MESA, Heinz Nixdorf, and AHA/ACC guidance to reclassify risk

Optimal CAC cut-point for ACS detection

Optimal cut-point for ACS detection (observational subgroup)22 (Agatston units) — reported optimal CAC cut-point for ACS detection in one observational analysis

Performance noteC statistic for CAC cut-point 22 = 0.81 in the reported cohort; CAC inferior to CCTA for ACS prediction

Population contextDerived from ED patients undergoing both CCTA and CAC scanning; ACS rate in cohort 8%

Agatston score risk categories noted

Example Agatston risk categories noted in studies0; 1–100; >400

Associated outcomesHigher MACE rates reported for CAC >400 versus 1–100 or 0 in symptomatic cohorts

Use in predictive modelsAdding CAC categories (eg, 0, 1–100, >400) improved model performance in cohort analyses

CAC score thresholds referenced across studies and guidelines

Thresholds referenced across studies/guidelines0; 1–99; 100; 400; 1000 (Agatston units)

Guideline linkAHA/ACC recommends interpretation using 0, 1–99, and ≥100 thresholds for statin decision-making in borderline/intermediate-risk patients

High-risk action thresholdsScores ≥400 (and in some protocols ≥1000) used to trigger more aggressive testing or ICA referral in cohorts

Inclusion rule for quantitative assessment

Inclusion rule for quantitative assessmentWhen quantitative CAC assessment is performed during the same encounter as contrast-enhanced cardiac CT (75572–75573) or coronary CT angiography (75574), it is included in that service (not billed separately)

Implication for billingSeparate billing for included quantitative calcium assessment may be denied or bundled

Relevant codesApplies when 75572, 75573, or 75574 are performed in same encounter as CAC quantification

Provider Actions and Billing Guidance

Denial Risk

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

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.

Billing Rule

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.

Billing Rule

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.

Denial Risk

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

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.

Note

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.

Note

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.

Billing Rule

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 Required

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.

Documentation Required

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.

Note

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.

Billing Rule

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.

Definitions

Agatston score definition

Agatston score definitionA weighted summed total of calcified coronary artery area observed on CT (Agatston method), expressed as an absolute number

Typical numeric rangeCommonly reported as 0 to ~400 for categorical risk, convertible to age- and sex-specific percentiles

PurposeUsed to quantify coronary calcium burden for risk stratification and diagnostic evaluation

EBCT definition

EBCT definitionElectron-beam computed tomography (EBCT; ultrafast CT) is an ultrafast CT method permitting quantification of coronary calcium area and density for use in CAC scoring

Technical advantageVery rapid image acquisition reduces motion artifact and permits visualization of coronary calcium

Comparable methodsMultidetector CT and CT angiography also measure CAC and provide similar information to EBCT

CAC categories definition (commonly reported categories)

Commonly reported CAC categoriesCAC = 0 (no detectable calcium); CAC 1–100 (mild); CAC >100 (moderate–high); CAC ≥400 (very high)

Clinical useCategories used to reclassify cardiovascular risk and guide decisions such as statin initiation or further testing

Percentile conversionAbsolute categories can be translated to age-, sex-, and race/ethnicity-specific percentiles when needed

Clinical utility definition

Clinical utility definitionUse of test results that informs management decisions leading to improved net health outcomes (eg, correct or more effective therapy or avoidance of unnecessary interventions)

Evidence requirementClinical utility depends on demonstrable clinical validity and impact on patient-important outcomes

ImplicationWithout RCT evidence of improved hard outcomes, clinical utility remains unproven despite risk reclassification

Agatston score (restate)

Agatston score restatedQuantitative CT-based measure of coronary artery calcium used to stratify atherosclerotic burden (Agatston method)

ApplicationUsed in asymptomatic risk stratification and symptomatic diagnostic algorithms

ConversionAbsolute scores convertible to age- and sex-specific percentiles

Outcomes of interest

Outcomes of interestOverall survival (OS); test accuracy/validity; major adverse cardiovascular events (MACEs); need for invasive coronary angiography and revascularization

Role in evidence chainThese outcomes inform clinical validity and the downstream clinical utility of CAC testing

Reported metricsStudies report sensitivity, specificity, predictive values, likelihood ratios, and event rates tied to CAC categories

CPT 75571 definition

CPT 75571 descriptionComputed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (CAC scoring)

Typical useNoncontrast cardiac CT for Agatston scoring and quantitative calcium assessment

Coding contextListed in the policy coding section for informational purposes; coverage determined by policy/contract

CPT 75574 definition

CPT 75574 descriptionComputed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material, including 3D image postprocessing

Typical useContrast-enhanced coronary CT angiography (CCTA) for coronary artery evaluation including 3D postprocessing

Relation to CACWhen performed with CAC quantification during same encounter, quantitative assessment is considered included in the service per policy coding guidance

75571 restated

75571 (restated)Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium

FunctionProvides Agatston score and quantitative assessment of coronary calcium burden

Billing noteIncluded in coding list; check member contract for coverage determinations

75574 restated

75574 (restated)Computed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material, including 3D image postprocessing

Use with CACCCTA may be used in tiered diagnostic pathways; when CAC quantification is performed in same encounter it is included in the CCTA service

Coding implicationProviders should not separately bill for quantitative CAC when performed with 75574 in same encounter per policy coding guidance

Noninvasive arterial plaque analysis codes (0710T-0713T) definition

0710T-0713T descriptionNoninvasive arterial plaque analysis using software processing of CT data including data preparation, quantification of vessel wall structure/composition, assessment for lipid-rich necrotic core, and report components

ComponentizationIncludes separate codes for data prep/transmission (0711T), quantification (0712T), and review/interpretation/report (0713T)

ContextListed as procedure codes for noninvasive plaque analysis in the policy coding section (informational)

OpenPayer

Coronary Artery Calcification (CAC) Scoring with CT

Coverage Criteria

Coding and Code Definitions

Provider Actions and Billing Guidance

Background and Rationale

Definitions