Fractional Flow Reserve from Computed Tomography (FFRct)
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Defines prior authorization, clinical eligibility, and procedural limitations for noninvasive Heartflow FFRct testing for members with suspected or known coronary artery disease in the Arkansas PASSE population.
No material clinical or coverage changes in this revision.
Coverage Criteria for FFRct
Covered when ALL of the following are met
FFRct is covered for noninvasive evaluation when all of the following conditions are satisfied:
Heartflow FFRct intended to be used with clinical history, symptoms, diagnostic tests, and clinician judgment
Prior authorization required; documentation should distinguish stable from unstable presentations (e.g., stable angina vs unstable angina)
The policy excludes use of FFRct for members with conditions or presentations where safety and effectiveness have not been established. Specifically, FFRct is not appropriate for individuals with suspected acute coronary syndrome (until acute MI or unstable angina are definitively ruled out), those with a recent myocardial infarction within 30 days, or members with complex congenital heart disease. It is also excluded for patients with a history of prior coronary artery bypass graft (CABG) surgery.
FFRct is further excluded for members with significant physiologic or clinical instability: those requiring emergent procedures or with evidence of active instability such as acute chest pain of sudden onset, cardiogenic shock, or unstable blood pressure with systolic blood pressure <90 mmHg. Severe heart failure (NYHA class III or IV) and acute pulmonary edema are additional exclusions. Finally, individuals with a body mass index >35 are excluded from evaluation with FFRct under this policy.
Coding Constraints and Clinical Metrics
Provider Actions, Authorization, and Documentation
Prior Authorization Required
Prior authorization is required.
- Prior authorization must include: a prescription; documentation supporting a clinically stable, symptomatic member with coronary artery disease (e.g., stable angina — not unstable angina).
- Requests without prior authorization may be denied.
Required Documentation for Authorization
Prior authorization submission must include the member's prescription and documentation that the member is clinically stable and symptomatic (supporting coronary artery disease). Examples: stable angina is appropriate; unstable angina or other signs of clinical instability are not appropriate.
Denial Risk for Missing Criteria
Requests that lack prior authorization or that do not include documentation of clinical stability and symptoms (per policy) are at risk for denial. Do not submit authorization for members with suspected acute coronary syndrome, recent MI within 30 days, prior CABG, complex congenital heart disease, BMI >35, or any evidence of ongoing clinical instability (e.g., acute chest pain, cardiogenic shock, systolic BP <90 mmHg, NYHA III–IV heart failure, or acute pulmonary edema).
Background
Coronary artery disease is the most common form of heart disease and a leading cause of mortality; evaluation of ischemia-causing coronary lesions is a central component of care. Invasive fractional flow reserve (FFR) is measured during coronary angiography by assessing pressure differences across a coronary stenosis to determine its physiologic significance. FFRct is a noninvasive alternative: it is a mathematically derived estimate of fractional flow reserve computed from a 3D model built from coronary CT images and simulated pressure, velocity, and blood flow data. Heartflow FFRct is performed using post-processing software applied to previously acquired CT images and is intended to aid determination of flow-limiting coronary stenoses when used alongside clinical history, other diagnostic tests, and clinician judgment.
Definitions
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