CurrentUnitedHealthcarePolicy MMP372.12

Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease

Defines UnitedHealthcare Medicare Advantage coverage, clinical indications, and coding for noninvasive fractional flow reserve derived from coronary CT angiography (FFR-CT) for evaluation of ischemic heart disease in clinically stable symptomatic patients and where applicable per LCDs/LCAs.

Policy Summary

PayerUnitedHealthcare

PolicyNon-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease

Policy CodePolicy MMP372.12

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain FFR-CT only after an interpreted CCTA showing 40-90% stenosis in proximal or mid coronary arteries and document post-processing interpretation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

75580Listed CPT code for FFR-CT

Class IIAAHA/ACC recommendation strength

22%FORECAST invasive angio reduction

82.2%Diagnostic accuracy (FFR-CT vs invasive)

Coverage Criteria for FFR-CT

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inv-01: Coverage — FDA-approved FFR-CT technology

Covered when ALL of the following are met:

Main coverage criteria: 1) The base coronary CT angiography (CCTA) has been completed and interpreted prior to FFR-CT processing.

FFR-CT must be applied as post-processing of previously acquired CCTA DICOM data and reported by a qualified clinician.

Stenosis on CCTA: 2) One or more coronary lesions with 40–90% stenosis on CCTA located in a proximal or mid coronary artery.40-90%

Coverage contingent on CCTA demonstrating 40-90% stenosis in proximal or mid coronary arteries.

Clinical status: 3) The patient is clinically stable and symptomatic (includes stable angina or appropriate intermediate‑risk acute presentations per LCD/LCA guidance).

Not intended for unstable coronary syndromes or when urgent/timely workup is required.

Technology and reporting: 4) An FDA‑approved FFR‑CT technology is used to perform post‑processing of the interpreted CCTA with interpretation and report by a qualified clinician.

FDA‑approved product required; see coding (CPT 75580) and regulatory product codes.

Sequencing / alternative to stress testing: 5) FFR‑CT is used as an alternative to stress testing and is not performed in conjunction with stress testing unless the CCTA quality precludes FFR‑CT.

FFR‑CT should not be used concurrently with stress testing except when CCTA is inadequate for FFR‑CT.

Exclusionary clinical circumstances: 6) None of the exclusionary clinical circumstances are present (see exclusions).

Exclusions include prior prosthetic valves, prior CABG grafts, intracoronary metallic stent, status post heart transplantation, recent MI ≤30 days, prior pacemaker/defibrillator leads, newly diagnosed systolic heart failure without prior left heart catheterization, non‑obstructing stenosis <50% without new symptoms, or when turnaround times would impact care.

inv-02: AHA/ACC guideline recommended use

Covered when AND clinically appropriate for patients meeting guideline-specified anatomic and risk categories:

AHA/ACC recommended indications: FFR‑CT is indicated to diagnose vessel‑specific ischemia and to guide decisions about coronary revascularization for patients with coronary stenosis of 40–90% in a proximal or mid coronary artery on CCTA in the following scenarios: (1) Intermediate‑risk with acute chest pain and previously unknown CAD; (2) Intermediate‑risk with stable chest pain and previously unknown CAD; (3) Intermediate‑risk with acute chest pain and known CAD; (4) Known nonobstructive CAD with stable chest pain and 40–90% stenosis on CCTA.stenosis 40-90%

Recommendation strength: Class IIA; Level of evidence B‑NR.

Imaging quality and timeliness caveat: Do not order FFR‑CT when CCTA imaging is suboptimal or extensive plaque is present such that a high‑quality CCTA is unlikely, or when delays in obtaining results could impact patient care.

Guideline specifies avoiding FFR‑CT in cases of poor CCTA quality or when turnaround time would affect management.

FFR-CT is not indicated in clinical contexts where the computational analysis of coronary CTA is unreliable or not applicable. Exclusionary circumstances include prior placement of prosthetic heart valves, prior coronary artery bypass grafts, presence of an intracoronary metallic stent, status post heart transplantation, recent myocardial infarction within 30 days, prior pacemaker or defibrillator lead placement, newly diagnosed systolic heart failure without a prior left heart catheterization, and cases with non‑obstructing stenosis (<50%) on prior CTA or catheterization in the past 12 months without new symptoms.

FFR-CT should not be ordered when the underlying CCTA is of suboptimal quality or when extensive plaque burden makes acquisition of a high‑quality CCTA unlikely. Additionally, FFR‑CT is inappropriate when delays in obtaining results could affect patient care and decision-making; in such cases an alternative diagnostic strategy should be used.

FFR-CT is considered not medically necessary in specific scenarios: when performed before the base CCTA has been completed and interpreted; for lesions with > 90% stenosis on CCTA (these patients should proceed directly to invasive catheterization); and for low‑grade stenoses (< 40% stenosis) that do not require additional confirmatory testing. FFR‑CT is also not indicated for unstable coronary syndromes or when urgent evaluation is required.

The policy notes limitations and cautions rather than additional standalone NMN statements: use of FFR‑CT is contraindicated in the exclusionary clinical circumstances listed above and when CCTA quality or turnaround time precludes reliable post‑processing. These practical exclusions should be reviewed prior to ordering to avoid inappropriate use.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization / coverage trigger

Prior authorization/coverage is contingent on use of FDA-approved FFR-CT technology only after a completed and interpreted coronary computed tomography angiography (CCTA) that demonstrates 40–90% stenosis in a proximal or mid coronary segment. FFR-CT must be performed as a post-processing analysis of previously acquired CCTA DICOM data and is intended as an alternative to stress testing.

FFR-CT may not be used before the base CCTA has been completed and interpreted.
FFR-CT is indicated only when CCTA demonstrates 40–90% stenosis in a proximal or mid coronary artery.
FFR-CT is intended as an alternative to stress testing and should not be used in conjunction with stress testing unless CCTA image quality is insufficient for FFR-CT and an alternative study is needed.

Prior Authorization

Follow delegate prior authorization

For members whose utilization management and prior authorization requirements are managed by a delegated organization, providers must follow the delegate's prior authorization and utilization management processes in place for that member.

Check the member's plan to determine if a delegate manages prior authorization and follow delegate-specific submission requirements and timelines.

Step Therapy

Step or sequencing requirement

FFR-CT is intended as an alternative to functional stress testing. Do not perform routine stress testing in combination with FFR-CT unless CCTA image quality prevents FFR-CT analysis and an alternative functional study is clinically required.

Perform FFR-CT only after CCTA interpretation and when criteria for FFR-CT are met.
Do not sequence FFR-CT in addition to stress testing except when FFR-CT is not feasible due to image quality or other documented technical limitations.

Documentation Required

Required documentation and workflow

FFR-CT analysis must be performed as post-processing of previously acquired CCTA DICOM data. The analytic results and supporting measurements must be provided to the interpreting clinician and included in the diagnostic report. Providers are expected to retain and make available documentation that supports medical necessity and the clinical interpretation.

FFR-CT must be performed on previously acquired CCTA DICOM datasets; do not submit FFR-CT performed on non-CCTA sources.
Include FFR-CT quantitative results and interpretation in the radiology report or consult note that documents the clinical decision-making.
Retain source CCTA DICOM images, FFR-CT analysis output, and the interpreting clinician's report in the medical record for audit or documentation requests.

Documentation Required

Documentation and claims submission

Providers must retain documentation to support coverage decisions and submit accurate claims reflecting the services rendered. Documentation should establish that FFR-CT criteria were met and that the base CCTA had been completed and interpreted prior to FFR-CT. Failure to provide appropriate documentation may result in denial or recoupment.

Keep documentation that demonstrates: qualified indication, CCTA interpretation showing 40–90% proximal or mid coronary stenosis, FFR-CT output and interpretation, and absence of exclusionary clinical circumstances (e.g., recent MI ≤30 days, intracoronary stent, prior CABG grafts, prosthetic valves, heart transplant, pacemaker/ICD leads).
Submit claims using the appropriate CPT/HCPCS codes and follow UnitedHealthcare and CMS coding guidelines; ensure claim line items and modifiers accurately reflect that FFR-CT was a post-processing of prior CCTA images.
Providers are responsible for accurate claims submission; retain records to respond to documentation requests or audits.

Denial Risk

Situations triggering potential denial

Services may be denied when required conditions are not met or when FFR-CT is used in clinical situations that the policy identifies as not medically necessary.

FFR-CT performed before the base CCTA is completed and interpreted.
CCTA demonstrates stenosis >90% (patient should proceed to catheterization) or stenosis <40% (no additional confirmatory testing indicated).
FFR-CT used in the presence of exclusionary clinical circumstances such as intracoronary metallic stent, prior CABG grafts, prosthetic valves, recent MI ≤30 days, heart transplant status, pacemaker/defibrillator leads, newly diagnosed systolic heart failure without prior catheterization, suspicion of acute coronary syndrome not yet ruled out, or when turnaround time would adversely impact care.
FFR-CT performed in clinically unstable patients or when urgent evaluation is required.

Note

Benefit plan governs coverage

Benefit plan terms govern actual coverage determinations. When there is a conflict between this policy and the member's specific benefit plan document, the member's benefit plan prevails.

Contact the member's customer service or review the Administrative Guide for benefit-specific coverage details.

Billing Rule

Documentation retention and billing responsibilities

Unlisted or incomplete documentation, or failure to follow applicable LCD/LCA and Medicare Advantage policy guidance, may result in claim denials or requests for additional information. Providers should follow CMS LCDs/LCAs where applicable and UnitedHealthcare instructions for Medicare Advantage plans.

Follow applicable LCDs/LCAs for Non-Invasive Fractional Flow Reserve and document compliance.
For members in delegated plans, follow the delegate's requirements for prior authorization and documentation submission.

OpenPayer

Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease

Coverage Criteria for FFR-CT

Coding and Regulatory Codes

Provider Actions, Prior Authorization, and Documentation

Background and Clinical Context

Definitions