CurrentBlue Cross Blue Shield - MassachusettsPolicy 915

Optical Coherence Tomography Policy

Defines coverage position for optical coherence tomography (OCT) in coronary applications for Commercial and Medicare products; specifies investigational/non-covered uses and prior authorization requirements for outpatient/inpatient settings.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyOptical Coherence Tomography Policy

Policy CodePolicy 915

Change TypeAnnual literature updates; policy statements unchanged

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for all products when OCT is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

Annual policy review updated with literature review through October 2022; references added; policy statements unchanged.

Policy updated with literature review through February 1 2020; references added; policy statements unchanged.

New policy describing non-coverage effective 02/04/2013.

1Investigational coverage stance

1Inpatient preauthorization required

4Products where outpatient not covered

Coverage Summary

Defines coverage position for optical coherence tomography (OCT) in coronary applications for Commercial and Medicare products. Coverage stance: Investigational / Not Covered (policy lists OCT as investigational when used as an adjunct to percutaneous coronary interventions with stenting and investigational for other uses such as risk stratification of intracoronary plaques and follow-up evaluation of stenting). Precertification/prior authorization is required for inpatient procedures. Outpatient OCT is not a covered service for Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM and may be denied if submitted as outpatient.

Medical Necessity / Authorization Rules

Investigational / Not Covered Uses

Optical coherence tomography is considered INVESTIGATIONAL in the following situations:

ALL of the following

When used as an adjunct to percutaneous coronary interventions with stenting: Optical coherence tomography is considered INVESTIGATIONAL
In all other situations, including but not limited to risk stratification of intracoronary atherosclerotic plaques and follow-up evaluation of stenting: Optical coherence tomography is considered INVESTIGATIONAL

Authorization / Coverage Setting Rules

Precertification / prior authorization requirements and outpatient coverage statement

ALL of the following

Precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient
Outpatient: This is not a covered service for Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM

Provider Actions & Operational Notes

Prior Authorization

Inpatient preauthorization required

Precertification/preauthorization is required for all products when OCT is performed inpatient.

Denial Risk

Outpatient not covered

Outpatient optical coherence tomography is not a covered service for Commercial PPO and Indemnity, Medicare HMO BlueSM, and Medicare PPO BlueSM and may be denied if submitted as outpatient.

Documentation Required

Verify member contract and code reporting

Providers must refer to the member's contract benefits to determine coverage and report services using current procedure, revenue, and diagnosis codes including modifiers where applicable.

General coding guidance: Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes; including modifiers where applicable.

Coding Guidance

CPT CodesCPT

There is no specific CPT code for this service.

General coding guidancemixed

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes; including modifiers where applicable. Inclusion or exclusion of a code does not imply member coverage; refer to member contract.

Background & Evidence Summary

Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique that uses near-infrared light to visualize coronary artery plaque characteristics and stent results. The evidence indicates OCT provides higher resolution and greater detail than intravascular ultrasound (IVUS) and is more sensitive for detecting some abnormalities. However, although OCT may detect additional findings and can be performed with high success and few complications, available evidence has not demonstrated that OCT-guided management leads to improved clinical outcomes; therefore clinical utility has not been established.

Policy literature review through October 2022: references and randomized trials reviewed through October 2022; evidence is insufficient to demonstrate clinical utility of OCT as an adjunct to percutaneous coronary intervention (PCI) with stenting, for plaque risk stratification, or for post‑stent follow-up. Although OCT may identify additional abnormalities compared with IVUS and could change management, current studies are limited in size and number and do not establish that OCT-guided strategies improve patient outcomes.

Definitions

OutpatientService setting billed as outpatient; policy states OCT is not a covered outpatient service for specified products.

Revision History

11/2022annual_reviewLatest