Retiredblue cross blue shield - kansasPolicy N/A

Cardiac Computed Tomography (CT)

This policy defines when Cardiac CT for evaluation of cardiac structure and morphology is considered medically necessary for Blue Cross and Blue Shield of Kansas members, with primary focus on congenital heart disease, preprocedural planning, and specific syndromic indications.

Policy Summary

Payerblue cross blue shield - kansas

PolicyCardiac Computed Tomography (CT)

Policy CodePolicy N/A

Change TypeArchived

Effective DateSeptember 11, 2012

Next Review DateN/A

Key ActionContact BCBSKS customer service or submit a predetermination request if there are questions about coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9listed medically necessary indications

2CPT codes listed

multipleICD-10 diagnosis codes enumerated

ARCHIVEDarchive status noted

Coverage Criteria

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Medically necessary indications: 1. Evaluation of the pulmonary veins in persons undergoing pulmonary vein isolation procedures for atrial fibrillation

Medically necessary indications: 2. Evaluation of persons needing biventricular pacemakers to accurately identify the coronary veins for lead placement

Medically necessary indications: 3. Suspected or known Marfan's syndrome

Medically necessary indications: 4. Evaluation of sinus venosum atrial-septal defect

Medically necessary indications: 5. Kawasaki's disease

Medically necessary indications: 6. Anomalous pulmonary venous drainage

Medically necessary indications: 7. Pulmonary outflow tract obstruction

Medically necessary indications: 8. Person scheduled or being evaluated for surgical repair of tetralogy of Fallot or other congenital heart disease

Medically necessary indications: 9. Evaluation of other complex congenital heart diseases

The coding section is provided for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, or device code(s) in this policy does not constitute or imply member coverage or provider reimbursement. Coverage for an individual service is determined by the member's contract benefits in effect at the time of service; consult the member’s contract and BCBSKS Customer Service or a predetermination request when coverage is uncertain.

Coding

Covered CPT CodesCPTCovered

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 and evaluation of venous structures, if performed)

ICD-10 Diagnoses (listed)ICD-10

A18.84	Tuberculosis of heart
I01.1	Acute rheumatic endocarditis
I05.0	Rheumatic mitral stenosis
I05.1	Rheumatic mitral insufficiency
I05.2	Rheumatic mitral stenosis with insufficiency
I05.8	Other rheumatic mitral valve diseases
I05.9	Rheumatic mitral valve disease, unspecified
I06.0	Rheumatic aortic stenosis
I06.1	Rheumatic aortic insufficiency
I06.2	Rheumatic aortic stenosis with insufficiency

1–10 of 126

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Provider Actions & Considerations

Prior Authorization

Contact BCBSKS / Predetermination

Contact Blue Cross and Blue Shield of Kansas (BCBSKS) Customer Service or submit a predetermination request if there are questions about coverage for this service. Policies may not reflect contract or state/federal mandates; verify benefits with BCBSKS Customer Service prior to performing services.

Contact BCBSKS Customer Service for benefit verification prior to service.
Submit a predetermination request when coverage is uncertain.
Member contract, state and federal mandates govern coverage — inclusion of codes in this policy does not guarantee coverage.

Note

Verify Member Benefits

Verify member benefits with Blue Cross and Blue Shield of Kansas Customer Service prior to scheduling or providing services to confirm eligibility, coverage limits, and applicable exclusions.

Confirm member-specific coverage, benefit limits, and any applicable preauthorization requirements.

Billing Rule

Coverage Determined by Member Contract

Inclusion of codes, procedures, diagnoses, or devices in this policy is for informational purposes only and does not imply coverage or reimbursement. Coverage is determined by the member's contract and any applicable state or federal mandates, which take precedence over this Medical Policy.

Do not assume coverage solely because a code appears in this policy.
Review the member's contract and any mandate language before billing.

Background

Cardiac Computed Tomography (CT) is used for the morphologic evaluation of the heart and related structures, including the cardiac chambers, valves, ventricular myocardium, coronary arteries and veins, aortic root, central pulmonary arteries and veins, and the pericardium. This policy focuses on use of Cardiac CT primarily in structural and congenital heart disease contexts and for preprocedural planning to guide interventions such as pulmonary vein isolation, coronary venous lead placement, and surgical repair of complex congenital lesions.

Definitions

Cardiac CT — definition of Cardiac Computed Tomography (CT).

TermCardiac Computed Tomography (CT)

DefinitionImaging performed primarily for the morphologic evaluation of the cardiac chambers, valves, ventricular myocardium, coronary arteries and veins, aortic root, central pulmonary arteries and veins, and pericardium.

Primary UsesEvaluation of cardiac structure and morphology for diagnostic and preprocedural planning purposes.

Related ActionsIf there are questions about coverage, contact BCBSKS customer service or submit a predetermination request.