Fractional Flow Reserve from Computed Tomography (FFRct)
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Medical policy governing use, prior authorization, and procedure limitations for noninvasive HeartFlow FFRct testing to evaluate coronary artery disease in symptomatic, clinically stable members; applies to CareSource members in Arkansas PASSE program.
No material clinical or coverage changes in this revision.
Coverage Criteria for FFRct
Covered indication — stable symptomatic CAD
Covered when ALL of the following are met
Per policy, prior authorization is required.
Prior authorization must include a prescription as specified in policy.
Documentation should demonstrate clinical stability; unstable angina is explicitly not a candidate.
HeartFlow FFRct is intended for use in conjunction with other clinical information.
Exclusion criteria include acute/unstable conditions, recent MI, prior CABG, BMI >35, complex congenital disease, or ongoing clinical instability.
The following populations are not evaluated / excluded for FFRct and are not considered appropriate candidates under this policy: suspicion of acute coronary syndrome where acute myocardial infarction or unstable angina have not been ruled out; recent myocardial infarction within 30 days; complex congenital heart disease; prior coronary artery bypass graft (CABG) surgery; members with a Body Mass Index >35; and members requiring emergent procedures or with evidence of ongoing clinical instability, including acute chest pain (sudden onset), cardiogenic shock, unstable blood pressure with systolic <90 mmHg, severe congestive heart failure (New York Heart Association [NYHA] III or IV), or acute pulmonary edema.
Prior authorization requirements and coverage limitations apply only to members who do not meet these exclusions. Failure to obtain prior authorization or to document clinical stability and symptomatic coronary artery disease may result in denial of coverage.
Key Parameters and Coding-related Limits
Provider Actions, Authorization and Documentation Requirements
Prior Authorization Required
Prior authorization is required for HeartFlow FFRct.
Provider: What to Submit
Provider action: submit a signed prescription and complete clinical documentation showing the member is clinically stable and symptomatic with suspected coronary artery disease. Do not submit for members with unstable symptoms or acute presentations.
- Signed prescription required
- Clinical documentation demonstrating stable, symptomatic CAD (e.g., stable angina)
- Do not request for unstable angina, acute chest pain, suspected acute coronary syndrome
Required Documentation
Required documentation for prior authorization must include a prescription and supporting clinical records that demonstrate the member is clinically stable and symptomatic. Examples of acceptable documentation include clinical notes describing stable angina symptoms, prior noninvasive testing results, and relevant diagnostic imaging reports.
- Prescription for HeartFlow FFRct
- Clinical notes showing stable, symptomatic coronary artery disease
- Results of prior noninvasive cardiac testing (if available)
- Diagnostic CT images/reports used to generate the FFRct model
Consequences of Missing Authorization/Documentation
Requests lacking prior authorization or missing the required prescription and supporting clinical documentation will be denied. Performing or billing for HeartFlow FFRct without an approved authorization may result in claim denial and financial liability to the provider.
- Denial risk if prior authorization is not obtained
- Denial risk if prescription or clinical documentation is incomplete or absent
Background
Coronary artery disease (CAD) is the most common form of heart disease and a leading cause of death. Invasive fractional flow reserve (FFR) measures intravascular pressure during coronary angiography to determine whether a stenosis impairs blood flow. FFRct is a noninvasive alternative in clinically stable, symptomatic members: a digital 3-D model is created from coronary CT images and a mathematically derived FFR value is computed from simulated pressure, velocity, and blood flow to help identify flow-restricting lesions. HeartFlow FFRct is post-processing software intended to be used in conjunction with clinical history, symptoms, diagnostic testing, and clinician judgment.
Definitions
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