ModifiedKaiser PermanentePolicy N/A

Cardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review Criteria

Customize your policy alerts

Sign up for all Kaiser Permanente policy alerts

Know when Kaiser Permanente releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical review criteria governing medical necessity determinations for cardiac computed tomography studies (including coronary CT angiography, coronary artery calcium scoring, CT-based FFR, and AI-enabled quantitative coronary plaque analysis) for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyCardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeCoding and policy consolidation updates

Effective DateJan 1, 2024

Last ReviewJul 10, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required; FFR-CT (CPT 75580) requires a CCTA performed within the prior 90 days and documentation that lesion criteria are met.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedKaiser PermanentePolicy N/A

Cardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review Criteria

Customize your policy alerts

Sign up for all Kaiser Permanente policy alerts

Know when Kaiser Permanente releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerKaiser Permanente

PolicyCardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeCoding and policy consolidation updates

Effective DateJan 1, 2024

Last ReviewJul 10, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required; FFR-CT (CPT 75580) requires a CCTA performed within the prior 90 days and documentation that lesion criteria are met.

SourceLink

POLICY UPDATE CHANGES

Updated CPT coding to replace Category III codes 0623T - 0626T with CPT 75577 for AI-enabled coronary plaque analysis.

Added new code 75580 effective 1/1/2024 and removed CPT 0501T–0504T which were deleted 1/1/2024 and replaced with 75580.

Merged CT angiography and Cardiac CT angiography policies and added Medicare LCD L39883 and billing/coding article for AI-enabled coronary topography (previously CPT 0623T-0626T).

75571, 75572-75574, 75577, 75580Key CPT codes addressed

Within 90 daysFFR-CT timing

>=5 yrsCAC repeat interval

0 / 1-99 / >=100CAC decision thresholds

Insufficient evidenceTechnologies lacking MTAC support

Coverage and Medical Necessity Criteria

Coverage criteria for CAC and FFR-CT

Coverage criteria summarized from Kaiser/MCG and adopted MAC/LCD guidance

CAC primary prevention criteria: Coronary artery calcium scoring may be indicated for asymptomatic adults age 40-75 when results would change managementSee CAC thresholds (CAC = 0; CAC 1-99; CAC >= 100 or >= 75th percentile)

Indicated for intermediate 10-year ASCVD risk (≥7.5% and <20%) or selected borderline risk (5–7.4%) when CAC would alter statin or risk‑factor treatment decisions; CAC=0 may allow withholding statin except in smokers or strong family history; CAC ≥100 or ≥75th percentile favors statin therapy.

FFR-CT criteria: FFR-CT (CPT 75580) is considered medically necessary when ALL of the following are met: patient has symptoms consistent with myocardial ischemia; CCTA was performed within the preceding 90 days; and there is at least one 40%–90% coronary stenosis in the proximal or mid segment of a major native coronary artery or a named branch of uncertain functional significance.Stenosis 40%–90%; timing ≤90 days

Adapted from local LCD guidance and MCG-based criteria.

Technology-specific coverage conclusions

Summary coverage determinations based on MTAC/MTAT evidence conclusions

Virtual coronary angioscopy for evaluation of coronary artery disease does not meet Kaiser Permanente Medical Technology Assessment Criteria.

Expected to be denied per MTAC conclusions.

EBCT / CAC scoring for treatment guidance: Use of EBCT for coronary artery calcium scoring and use of CAC to guide treatment decisions do not meet MTAC criteria for demonstrating improved patient outcomes despite providing prognostic information.

Observational evidence shows graded association with ASCVD risk but lacks RCTs showing CAC‑guided treatment improves outcomes.

64-slice MDCT/MDCT angiography: Use of 64-slice MDCT for diagnosis of coronary artery stenosis in selected nonemergent symptomatic patients demonstrates high sensitivity and NPV but lower specificity; evidence is insufficient to show improved management or net health outcomes and is not supported for screening asymptomatic or low‑risk individuals.

Accuracy varies by artery; many studies excluded patients with very high CAC or extreme BMI.

General medical necessity

Cardiac CT (including CTA, FFRCT) and coronary calcium scoring coverage depends on meeting applicable policy statements' medical necessity criteria.

General requirement: Services (CCTA, FFR-CT, and Coronary Artery Calcium scoring) are considered medically necessary only when the specific criteria in the applicable policy statements are met.

Verify plan-specific authorization requirements via the Pre-authorization Code Check.

CT-based cardiac techniques, including electron beam CT (EBCT)/ultrafast CT and multislice CT (MDCT), are not supported as a general screening test for asymptomatic, low-risk individuals. Multiple MTAC evidence reviews concluded there is insufficient evidence that these modalities as screening tools improve clinical outcomes, and studies report limitations such as motion artifacts, inability to determine functional significance without additional testing, poor performance in heavily calcified vessels, limited in-stent visualization, contrast exposure, and higher radiation dose compared with invasive angiography that limit their suitability for broad population screening.

When used diagnostically in selected symptomatic patients, MDCT (including 64-slice scanners) may show high sensitivity and negative predictive value but lower specificity, producing false positives that often require confirmation with invasive coronary angiography or stress testing. These performance characteristics and the lack of demonstrated improvement in patient management or net health outcomes are reasons screening asymptomatic low-risk populations is not supported.

Use of virtual coronary angioscopy is explicitly stated to not meet Kaiser Permanente Medical Technology Assessment Criteria (MTAC) for evaluation of coronary artery disease and is not supported as a covered diagnostic approach.

Similarly, EBCT (ultrafast CT) for coronary artery calcium (CAC) scoring has been reviewed and determined to not meet MTAC criteria for guiding treatment decisions. While CAC provides prognostic information about ASCVD risk, the MTAC reviews found insufficient randomized controlled trial evidence that CAC-guided treatment strategies improve outcomes, and therefore EBCT-based CAC scoring is not supported for use to guide therapy.

For Medicare members, the policy denotes that the Coronary Artery Calcium (CAC) Score is considered not medically necessary in specified contexts. For non‑Medicare members, CAC may be considered medically necessary when the applicable policy criteria are met, but plan-specific differences and the MTAC conclusions about limited evidence for CAC-guided treatment should be taken into account when determining coverage.

Documentation and authorization requirements differ by plan and Medicare status; verify specific requirements using the Pre-authorization Code Check and ensure clinical indications align with the policy statements that permit CAC measurement.

The policy states that use of ultrafast CT/EBCT or MSCT as a screening test for coronary artery disease in asymptomatic, low-risk individuals is not supported due to insufficient evidence. MTAC reviews and subsequent evidence summaries indicate that while EBCT/MDCT can detect coronary calcification and show high sensitivity in selected symptomatic cohorts, there is no demonstration that such screening leads to behavior change or improved long‑term outcomes in asymptomatic populations.

Furthermore, diagnostic limitations—such as low specificity at low calcium thresholds, variability across studies, selection bias in cohorts evaluated, and lack of RCTs showing outcome benefit—support the determination that these CT-based methods are not appropriate for general population screening.

Applying CT technologies (including CAC scoring, CCTA, and related postprocessing) for screening healthy, asymptomatic low‑risk individuals or using CAC results to direct treatment decisions is not supported. Longitudinal observational studies show CAC correlates with 10‑year ASCVD risk, but MTAC found insufficient evidence from randomized controlled trials that CAC‑guided management improves clinical outcomes.

Accordingly, CAC and other CT modalities should be reserved for situations where results would meaningfully change management in individuals who meet the specific clinical criteria described in the policy (for example, selective use in asymptomatic adults aged 40–75 at intermediate ASCVD risk), rather than routine screening of low‑risk healthy populations.

For Medicare coverage, the policy clarifies that the Coronary Artery Calcium Score is considered not medically necessary in certain contexts; non‑Medicare determinations may consider CAC medically necessary only when the detailed policy criteria are satisfied. The MTAC conclusion that CAC lacks RCT evidence demonstrating that CAC‑guided treatment improves outcomes underpins the more restrictive Medicare stance reflected in the policy.

Providers should confirm Medicare versus non‑Medicare coverage rules and ensure that clinical indications and documentation meet the applicable policy criteria before performing or billing for CAC studies.

Appropriate Indications and Use

Appropriate indications for CT-based cardiac imaging

CAC indication: Asymptomatic adults age 40–75 with intermediate 10‑year ASCVD risk (≥7.5% and <20%), or select adults with borderline risk (5–7.4%) when CAC results would change statin or risk‑factor management.Age 40–75; 10‑year ASCVD risk thresholds as stated

Repeat CAC measurement not indicated within less than 5 years; CAC thresholds guide therapy decisions (CAC=0, 1–99, ≥100/≥75th percentile).

CCTA/FFR-CT indication: Symptomatic patients with suspected myocardial ischemia where noninvasive anatomic (CCTA) or physiologic (FFR-CT) assessment would affect management; FFR-CT further requires a prior CCTA within 90 days and lesions of uncertain functional significance (40%–90% stenosis in proximal or mid segments).Lesion stenosis 40%–90%; CCTA within 90 days

CCTA primarily for stable patients at low–moderate pretest probability; limitations include arrhythmia, heavy calcification, stents, and contrast/renal contraindications.

CPT and Billing Codes

Covered/Addressed CPT CodesCPT

75571	Coronary artery calcium score; non-contrast study
S8092	Coronary artery calcium score, non-invasive (alternate/HCPCS listed in doc)
75572	CCTA coronary artery imaging (per document grouping)
75573	CCTA additional code (per document grouping)
75574	CCTA additional code (per document grouping)
75577	Artificial Intelligence Enabled CT Based Quantitative Coronary Topography / Coronary Plaque Analysis
75580	CT Fractional Flow Reserve (FFR-CT)

Referenced MAC/LCA billing guidancemixed

A57552	MAC Billing and Coding reference for CCTA (addresses 75572-75574, and 75571)
A58095	LCA Billing and Coding: Non-Invasive FFR-CT (addresses CPT 75580)
A59769	Billing and Coding: AI-QCT / AI-CPA (CPT 75577)

Cardiac CT / FFRCT 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 image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous 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).
75580	Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional.

Coronary Artery Calcium Score CodesCPT | HCPCS

75571	Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
S8092	Electron beam computed tomography (also known as ultrafast CT, cine CT).

AI-enabled CT Based Quantitative Coronary TopographyCPTCovered

75577

Quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary computed tomographic angiography, with interpretation and report by a physician or other qualified health care professional.

Coronary artery calcium score thresholds — CAC categories used for risk stratification

CAC = 0No detectable coronary artery calcium; may support withholding or delaying statin therapy except in smokers or strong family history of premature ASCVD.

CAC 1-99Low to moderate coronary calcification; favors initiation of statin therapy especially in patients ≥55 years.

CAC ≥100 or ≥75th percentileHigh coronary calcification burden; statin therapy is indicated.

FFRCT ischemia threshold — operational threshold (>= 0.80)

FFR-CT ischemia threshold>= 0.80 indicates low probability of inducible ischemia; PCI generally not indicated for that lesion.

Prior Authorization and Operational Rules

Prior Authorization

Prior authorization required for FFR‑CT and AI‑QCT

FFR‑CT (CPT 75580) and AI‑enabled QCT (CPT 75577) are subject to prior authorization consistent with the clinical criteria; FFR‑CT requires that a diagnostic CCTA was performed within the prior 90 days and that there is documentation of at least one 40%–90% coronary stenosis in the proximal or mid segment of a major native coronary artery or named branch of uncertain functional significance.

FFR‑CT (CPT 75580) requires prior CCTA within 90 days.
FFR‑CT requires documentation of a 40%–90% proximal or mid–segment stenosis of uncertain functional significance.
Prior authorization follows referenced MAC/LCD and MCG guidance for medical necessity determinations.

Prior Authorization

Select MDCT/64‑slice CT for appropriate nonemergent symptomatic patients (not screening)

Use MDCT/64‑slice CT angiography only for selected nonemergent symptomatic patients consistent with study populations (not for screening asymptomatic, low‑risk individuals); prior authorization may be used to confirm appropriate patient selection.

Documentation, Submission, and Denial Triggers

Prior Authorization

Ensure nonemergent symptomatic patient selection for MDCT/64‑slice CT; authorize as required

Select patients for MDCT/64‑slice CT only in nonemergent, symptomatic scenarios consistent with trial populations; prior authorization may be required to confirm indications and ensure the patient is not an asymptomatic screening case.

Step Therapy

ED triage: consider conventional pathways first—MDCT lacks proven ED management benefit

For ED patients with acute chest pain, evidence is insufficient that MDCT angiography changes management; consider conventional ED evaluation pathways before ordering MDCT for triage purposes.

Documentation Required

Include last 6 months of clinical notes with authorization request

Contraindications and Technical Contrast Guidance

Billing Rule

Contraindications to contrast: severe iodinated‑contrast allergy and creatinine > 1.5 mg/dL

Contraindications to CT coronary angiography include a history of severe allergic reaction to iodinated contrast and impaired renal function (creatinine > 1.5 mg/dL); assess renal function and allergy history before contrast administration.

Billing Rule

Document technical parameters and comparator for MDCT/CT angiography studies

Include study technical and comparator details (e.g., MDCT slice count and whether invasive coronary angiography served as the gold standard) when available, as these parameters were used in clinical studies comparing MDCT/CT angiography to invasive angiography.

Billing Rule

Excluded/Not Medically Necessary Services

Ultrafast CT/EBCT and multislice CT (MSCT) used as a population screening test for coronary artery disease in asymptomatic, low‑risk populations are explicitly listed as not covered. MTAC reviews concluded there is insufficient evidence to support screening use because studies do not demonstrate improved health outcomes from such screening and often involve selected or higher‑risk cohorts that limit generalizability.

Given these evidence limitations and known technical constraints (e.g., motion artifacts, reduced accuracy with heavy calcification, and radiation/contrast exposure), these CT modalities should not be used or billed as general CAD screening in asymptomatic low‑risk individuals.

Virtual coronary angioscopy and EBCT for coronary artery calcium scoring to guide treatment decisions are designated as not covered. The MTAC determinations found that virtual angioscopy does not meet technology assessment criteria, and EBCT/CAC lacks RCT evidence that CAC‑guided treatment improves outcomes; therefore these applications are excluded from coverage when used to direct therapy.

These exclusions apply even when CAC or virtual angioscopy findings might provide prognostic information—coverage depends on evidence that use changes management in ways that improve health outcomes, which is not supported for these technologies in the contexts specified.

Virtual coronary angioscopy is listed as not covered for evaluation of coronary artery disease because it does not meet Kaiser Permanente MTAC criteria. This inventory includes repeated/duplicate entries emphasizing that virtual angioscopy is unsupported for CAD evaluation.

Claims for virtual angioscopy as a diagnostic modality should be expected to be denied unless alternative coverage criteria that meet MTAC standards are documented and met.

The policy repeatedly excludes virtual coronary angioscopy and EBCT applications from coverage in contexts where they would be used to guide treatment decisions. These duplicate inventory entries underscore that such uses are consistently considered unsupported by MTAC evidence conclusions and therefore not covered.

Definitions and Key Terms

CCTA / Cardiac CT definition — MDCT multislice CT angiography definition and purpose

DefinitionComputed tomography angiography of the coronary arteries using multislice/MDCT technology to visualize coronary anatomy and stenoses.

Alternate namesCardiac CT, Coronary CT Angiography (CCTA), Multidetector Row Spiral CT, Multislice Detector CT.

PurposeNoninvasive evaluation of coronary artery lumen and stenosis to aid diagnosis and triage of suspected CAD; positive findings often require confirmation with invasive coronary angiography or functional testing.

Coronary Artery Calcium (CAC) Score definition — CT-derived quantitative measure for risk stratification

DefinitionA CT-derived quantitative measure of coronary calcified atherosclerotic burden used for cardiovascular risk stratification in asymptomatic patients.

Clinical role

Repeat Testing and Frequency Guidance

CT (CAC) — repeat coronary artery calcium measurement not indicated within less than 5 years

Repeat intervalRepeat coronary artery calcium measurement is not indicated within less than 5 years.

ModalityApplies to non-contrast CT coronary artery calcium scoring (CPT 75571 / S8092).

RationaleAdapted from KPWA ASCVD Primary Prevention guidance to avoid unnecessary repeat testing in short intervals.

Background and Evidence Overview

Background: Coronary artery disease is a leading cause of morbidity and mortality, and invasive coronary angiography remains the diagnostic gold standard but is invasive and often yields normal results. Noninvasive CT‑based modalities (CAC scoring, coronary CT angiography, FFR‑CT, and AI‑enabled plaque analysis) have emerged to evaluate coronary anatomy and potential ischemia, but they have notable limitations—motion artifacts, difficulty assessing heavily calcified lesions and in‑stent segments, need for contrast and radiation exposure, and limited proven impact on clinical outcomes when used broadly for screening or to guide therapy.

These limitations and the mixed strength of the evidence base (for example, moderate clinical validity but low clinical utility for FFR‑CT, and association but not outcome‑proven benefit for CAC) are the basis for policy determinations that emphasize selective, criteria‑based use rather than general population screening.

Policy Summary

PayerKaiser Permanente

PolicyCardiac CT (CCTA), Coronary Calcium Scoring, FFR-CT, and AI-enabled CT Plaque Analysis — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeCoding and policy consolidation updates

Effective DateJan 1, 2024

Last ReviewJul 10, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required; FFR-CT (CPT 75580) requires a CCTA performed within the prior 90 days and documentation that lesion criteria are met.

SourceLink

On This Page

MDCT use in ED/acute chest pain: MDCT angiography for emergency department patients with acute chest pain has insufficient evidence of benefit on management or outcomes; available ED studies did not evaluate the impact of CT results on treating clinicians' decisions.

ROMICAT and other ED studies provided limited applicability to clinical utility.

FFRCT evidence summary: FFR-CT has a large body of literature with moderate-quality evidence for clinical validity but low-quality evidence for clinical utility per HTA reports and MTAT review.

Additional clinical utility and long‑term outcomes data are needed.

Appropriate use considerations for CT coronary imaging

Selection and appropriateness considerations for CT coronary imaging

Nonemergent symptomatic selection: MDCT/64‑slice CCTA may be considered for diagnostic evaluation in selected nonemergent symptomatic patients referred for invasive coronary angiography in study‑like populations, recognizing high sensitivity and NPV but variable specificity.

Many studies excluded patients with CAC >600 or BMI >40; per‑segment and per‑vessel accuracy varies by coronary artery.

ED triage and acute chest pain: Use of MDCT angiography for ED patients with acute chest pain has insufficient evidence to demonstrate improved clinical management or outcomes and should not routinely replace standard ED evaluation pathways.

ROMICAT and other ED studies did not provide CT results to treating clinicians, limiting conclusions about impact on management.

Assessment of intermediate coronary stenosis/ischemia risk

Assessment of intermediate coronary stenosis/ischemia risk — when physiologic assessment may be useful

Indication: Patients with suspected or known coronary artery disease in whom noninvasive assessment of the hemodynamic significance of coronary stenosis using FFR-CT could affect management decisions.

Most studies included stable chest pain populations; FFR‑CT is more accurate than CCTA alone for detecting hemodynamically significant stenosis but clinical utility and long‑term outcomes evidence are limited. An FFR-CT value ≥0.80 indicates low probability of inducible ischemia and that PCI is generally not indicated for that lesion.

Operational useFFR-CT provides a noninvasive estimate of lesion hemodynamic significance derived from CCTA data via specialized software.

Clinical implicationValues below 0.80 suggest higher likelihood of ischemia and potential consideration for invasive evaluation or revascularization.

MDCT/64‑slice CT was evaluated in selected patients referred for invasive angiography and is not assessed for screening healthy, asymptomatic, or low‑risk individuals.
Accuracy in study populations showed high sensitivity and NPV but lower specificity; ensure the patient matches the nonemergent symptomatic populations studied.

Prior Authorization

Verify prior authorization for Cardiac CTA and FFR‑CT per plan

Verify plan‑specific authorization requirements before scheduling CCTA or FFR‑CT; Cardiac CTA (CPT 75572–75574) and FFR‑CT (CPT 75580) are considered medically necessary only when the applicable policy criteria are met and authorization rules apply per plan.

CPT 75572–75574 and CPT 75580 are listed as medically necessary when policy criteria are met; use the Pre‑authorization Code Check to verify authorization by plan.
Services that do not meet the applicable policy statements may be considered not medically necessary and denied.

Prior Authorization

Prior authorization requirement for Cardiac CTA/FFR‑CT

Prior authorization is required per the clinical criteria: Cardiac CTA and/or FFR‑CT are considered medically necessary only when the applicable policy statements' criteria are met; confirm authorization status with the member’s plan.

Ensure documentation demonstrates the service meets the policy criteria before requesting authorization.
Use plan tools (Pre‑authorization Code Check) to confirm whether authorization is needed for the listed CPT codes.

Prior Authorization

Prior authorization tied to specific clinical criteria and referenced guidance

Prior authorization decisions follow the policy clinical criteria: FFR‑CT (CPT 75580) requires a prior diagnostic CCTA within 90 days and lesion documentation; coronary calcium scoring and CCTA determinations follow MCG or adopted MAC/LCD guidance.

CPTs subject to prior authorization include 75580, 75571, 75572, 75573, 75574, and 75577 per the policy.
MCG criteria are used for CCTA medical‑necessity determinations for non‑Medicare members; MAC/LCD guidance is referenced for Medicare members.

Note

MDCT/64‑slice CT — ensure patient selection matches evidence populations

MDCT/64‑slice CT angiography selection considerations reiterated: restrict use to selected nonemergent symptomatic patients consistent with the evidence base and avoid use for asymptomatic screening.

Studies evaluated MDCT in patients referred for invasive angiography; CORE‑64 and ACCURACY had exclusions that affect applicability to broader populations.
Do not use MDCT/64‑slice CT as a screening test for asymptomatic, low‑risk individuals.

Submit the last 6 months of clinical notes from the requesting provider and/or cardiology specialist to support medical necessity when requesting Cardiac CTA or FFR‑CT.

Documentation Required

Document comparator and technical/study selection details (e.g., invasive angiography, slice count)

When documentation references comparative studies or diagnostic pathways, indicate whether invasive coronary angiography was used as the comparator and include technical parameters (e.g., scanner slice count) and patient selection details.

Documentation Required

Document that policy criteria are met for Cardiac CTA and FFR‑CT services

Provide documentation that clearly supports how the requested Cardiac CTA or FFR‑CT meets the applicable policy criteria for the billed CPT codes (e.g., timing of prior CCTA for FFR‑CT and lesion severity thresholds).

Denial Risk

Insufficient documentation may prevent support of medical necessity and lead to denial

If the submitted documentation is insufficient—such as missing the last 6 months of clinical notes—medical necessity may be unable to be supported and the request could be denied.

Denial Risk

Virtual coronary angioscopy is not supported and expected to be denied

Do not use virtual coronary angioscopy for CAD evaluation; this technology does not meet Kaiser’s MTAC criteria and would be expected to be denied.

Denial Risk

EBCT/CAC scoring not supported for treatment guidance—risk of denial

Do not use EBCT/CAC scoring to guide treatment decisions; EBCT‑based CAC scoring for treatment guidance does not meet MTAC criteria and may be denied when used for unsupported indications.

Denial Risk

Services not meeting medical necessity criteria for CTA/FFR‑CT may be denied

Requests that do not meet the policy’s medical necessity criteria for CTA and/or FFR‑CT may be considered not medically necessary and denied.

Perform CCTA with contrast according to CPT descriptions and clinical protocols

Perform CCTA with contrast material per CPT descriptions (CPT 75572–75574) and clinical protocols to evaluate cardiac structure, morphology, and coronary arteries.

Codes: CPT 75572, 75573, 75574

Providers should refer to the policy’s covered indications and medical necessity criteria for acceptable uses of CT cardiac imaging and avoid billing these excluded techniques for treatment‑guiding purposes.

May reclassify 10-year ASCVD risk and influence statin decisions in intermediate or borderline risk adults (commonly age 40–75).

LimitationsNo RCT evidence showing CAC-guided treatment improves long-term outcomes; not supported as a general screening test for low-risk asymptomatic individuals.

FFR-CT definition — noninvasive CT-derived fractional flow reserve

DefinitionNoninvasive CT-derived fractional flow reserve performed on CCTA data using augmentative software to estimate the functional significance of coronary stenoses.

Intended useEstimate whether a coronary stenosis causes an appreciable reduction in blood flow and may guide need for PCI versus medical therapy.

Evidence summaryLarge body of literature exists; clinical validity rated moderate and clinical utility rated low per HTA/MTAT reviews.

AI-QCT / AI-CPA definition — AI-enabled CT-based quantitative coronary topography/plaque analysis

DefinitionArtificial intelligence–enabled CT-based quantitative coronary topography or plaque analysis applied to CT images to characterize and quantify coronary plaque.

ApplicationPostprocessing/augmentative software applied to CCTA datasets to quantify plaque burden and characteristics (AI-QCT / AI-CPA, CPT 75577).

Coverage notePolicy references AI-QCT/AI-CPA but evidence and coding updates are addressed via applicable MAC/LCD and CPT changes.

Coronary Artery Calcium (CAC) score (repeated definition) — quantitative measure used as a risk marker

DefinitionQuantitative measure of coronary calcification on CT used as a risk marker associated with 10-year ASCVD risk in asymptomatic adults.

Clinical interpretationCAC results (e.g., 0, 1–99, ≥100) inform ASCVD risk reclassification and potential statin decisions in select adults age 40–75.

Policy stanceCAC scoring provides prognostic information but lacks RCT evidence to demonstrate CAC-guided treatment improves outcomes per MTAC review.

Fractional Flow Reserve Computed Tomography (FFRCT) — CT-based software method evidence summary

DefinitionA CT-based software method (e.g., HeartFlow) estimating physiologic lesion significance noninvasively from CCTA datasets.

Evidence summaryModerate-quality evidence for clinical validity but low-quality evidence for clinical utility; large literature base reviewed by MTAT/HTAs.

Operational noteFFRCT processing is performed on previously obtained CCTA images at centers with specialized software; clinical use requires careful patient selection per policy criteria.

FFRCT concise definition — noninvasive estimate of coronary fractional flow reserve from CCTA data

Concise definitionA noninvasive estimate of coronary fractional flow reserve derived from augmentative software analysis of CCTA data to assess hemodynamic significance of coronary lesions.

FunctionModels fluid dynamics from CCTA to estimate pressure changes across stenoses, serving as a noninvasive alternative to wire-based invasive FFR.

DeliveryRequires existing CCTA images and interpretation by qualified personnel; reported as a numeric FFRCT value per lesion.

FFRCT threshold definition — FFRCT value >= 0.80 indicates low probability of inducible ischemia

ThresholdAn FFRCT value ≥ 0.80 generally indicates a low probability of inducible ischemia and that PCI is not indicated for that lesion.

Clinical actionFFRCT ≥ 0.80 supports conservative/medical management; FFRCT < 0.80 may prompt consideration of invasive functional testing or revascularization.

ContextThreshold interpretation aligns with invasive FFR conventions and is applied per-policy when determining medical necessity and management implications.