Sign up for univerahealthcare Policy 6.01.34 alerts
Get alerted when Policy 6.01.34 changes without checking for updates manually.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Criteria governing medical appropriateness of CCT/CCTA for evaluation of suspected coronary artery disease in patients with new, recurrent, or worsening chest pain or exertional symptoms; applies to Univera Healthcare members.
Key ActionEnsure prior authorization and documentation show the indication aligns with policy criteria when requesting CCTA, including required prior testing and clinical risk factors.
New criteria for individuals with prior history of cardiac surgeries or history of CAD were added during an off-cycle review.
Clarification was added to the criteria for preoperative assessment for planned liver or kidney transplant.
Additional risk factors (hyperlipedemia and history of adverse pregnancy outcomes) were added and chest pain with syncope was added as an indication in an earlier off-cycle review.
Codes were edited: 75577 was added; CPT Category III codes 0623T-0626T were deleted.
New medically necessary criteria for Coronary CTA plaque quantification were added.
A policy guideline regarding Cardiac CT for TAVR was moved to a not medically necessary policy statement.
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.
CAC > 100
CAC threshold
>=50 & 2 RFsAge + risk factors
EF < 50%EF threshold
unstable CADPlaque quant not for
75572-75580CPT codes listed
06/18/26Last revision date
Medically Appropriate Indications and Exclusions
Medically Appropriate Indications
Covered when ANY of the following symptomatic scenarios or risk-based conditions are present
Symptom: cardiac-type chest pain: New, recurrent or worsening cardiac chest pain (defined as chest, epigastric, shoulder, arm/jaw pain, chest pressure or discomfort).
Symptom: exertional symptoms with additional criteria: New, recurrent or worsening symptoms of chest pain, unexplained exertional dyspnea, or unexplained exertional fatigue AND any of the following: symptoms persist after a normal stress test; equivocal, borderline, abnormal, or discordant prior noninvasive evaluation since symptom onset where obstructive CAD remains a concern; new abnormal rest ECG findings since symptom onset (e.g., new LBBB or T-wave inversions, excluding isolated T-wave inversion in lead III or V1-2) when ischemia is a concern; prior history of CABG when the only concern is graft patency; urgent evaluation (ER or urgent care) since onset; history of cardiac transplant (concern for transplant vasculopathy); chest pain occurring with syncope; history of chest radiation; coronary artery calcium (CAC) score > 100; or age ≥ 50 years with ≥ 2 cardiovascular risk factors (diabetes mellitus; current cigarette smoking; family history of premature CAD; hypertension; hyperlipidemia; history of adverse pregnancy outcomes).CAC > 100; age >=50 with >=2 risk factors
Bundles multiple conditional items as listed in policy.
Prior PCI/CABG or obstructive CAD with symptoms
Covered when a patient has prior PCI or CABG or history of obstructive CAD and ANY of the following:
Symptoms with prior revascularization or obstructive CAD: Cardiac chest pain.
Applicable when there is prior PCI, CABG, or history of obstructive CAD.
Symptoms with prior revascularization or obstructive CAD: Anginal equivalents such as atypical chest pain, exertional dyspnea, or exertional fatigue.
Symptoms with prior revascularization or obstructive CAD: Symptoms similar to prior ischemic episodes.
Anomalous coronary artery evaluation (age <40)
Covered for individuals under 40 years for suspected anomalous coronary artery or treatment planning when ONE or more of the following are present:
Anomalous coronary evaluation criteria: Syncopal episodes during strenuous activities.
Anomalous coronary evaluation criteria: Persistent exertional or stress-induced chest pain with a normal stress test.
Anomalous coronary evaluation criteria: Full sibling(s) with history of sudden death before age 40 or documented anomalous coronary artery.
Anomalous coronary evaluation criteria: Resuscitated sudden death and contraindications for conventional coronary angiography.
Anomalous coronary evaluation criteria:
Hypertrophic cardiomyopathy with stable angina
Covered as an initial imaging study for:
HCM with anginal symptoms: Individuals with hypertrophic cardiomyopathy and stable anginal symptoms.
Initial imaging study.
Recovered unexplained sudden cardiac arrest
Covered in lieu of invasive coronary angiography when BOTH of the following are determined:
Post-arrest evaluation: Confirm the presence or absence of ischemic heart disease; AND exclude the presence of an anomalous coronary artery.
Used for individuals recovered from unexplained sudden cardiac arrest.
Newly diagnosed congestive heart failure or cardiomyopathy
Covered for evaluation of newly diagnosed congestive heart failure or cardiomyopathy when ALL of the following are met:
Newly diagnosed heart failure/cardiomyopathy - criterion 1: No prior history of coronary artery disease.
Newly diagnosed heart failure/cardiomyopathy - criterion 2: Ejection fraction is less than 50%.< 50%
Newly diagnosed heart failure/cardiomyopathy - criterion 3: Low or intermediate risk on the pre-test probability assessment.
Newly diagnosed heart failure/cardiomyopathy - criterion 4: No contraindications to cardiac CT angiography.
Newly diagnosed congestive heart failure or cardiomyopathy
Evaluation of newly diagnosed congestive heart failure or cardiomyopathy — CCTA is indicated when ALL of the following are met
No contraindications to cardiac CT angiography.
No prior testing since diagnosis: No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy.
Other specified indications
Other covered indications (each is an independent indication as listed):
Structural heart disease for class IC agents: Evaluation of structural heart disease for use of class IC antiarrhythmic agents (flecainide or propafenone) in lieu of stress test with imaging.
Ventricular arrhythmia indications: Ventricular tachycardia (3-beat runs or greater), exercise-induced VT, or ventricular fibrillation.
Cardiac CTA will replace conventional invasive coronary angiography for preoperative assessment of the coronary arteries in planned surgery for any of the following:
Aortic dissection.
Aortic aneurysm.
Valvular surgery.
Liver transplant assessment: Liver transplant for initial pre-treatment evaluation (may be repeated once in three years).may be repeated once in 3 years
Systemic vasculitis — coronary assessment
To assess coronary involvement in individuals with systemic vasculitis when there are clinical features suggestive of underlying vasculitis, CCTA is indicated if ANY of the following are present:
Constitutional symptoms such as fevers, chills, night sweats, or weight loss.
Multiple visceral infarcts in the absence of an embolic etiology.
Cardiac trauma
Cardiac trauma.
CCTA for systemic vasculitis
Covered when ANY of the following clinical features suggesting vasculitis are present:
vasculitis_features: Multiple visceral infarcts in the absence of embolic etiology; cardiac trauma; or other clinical features suggestive of underlying vasculitis (e.g., Giant Cell Arteritis, Takayasu's, Kawasaki's disease).
Derived from listed examples in policy.
Preoperative CCTA for transplant candidates
Covered when ALL of the following apply:
transplant_preop_high_or_intermediate: Planned liver or kidney transplant candidate AND either: high-risk surgery (requires imaging stress test if none within 1 year unless new symptoms/ECG changes) OR intermediate-risk surgery with one or more clinical risk factors and unable to perform ETT when no imaging stress test within 1 year unless new symptoms/ECG changes.imaging stress test within 1 year
Clinical risk factors include history of ischemic heart disease; compensated CHF; prior TIA/stroke; diabetes mellitus; creatinine >2 mg/dL.
clinical_risk_factors: Clinical risk factors: history of ischemic heart disease; history of compensated congestive heart failure; history of prior TIA or stroke; diabetes mellitus; creatinine > 2 mg/dL.
These inform intermediate-risk surgery criteria.
Noninvasive FFR-CT
Covered when ALL of the following apply:
ffr_ct_after_ccta: Noninvasive FFR-CT is used to further assess coronary artery disease seen on a recent coronary CTA when the physiologic significance of lesions is uncertain.
FFR-CT considered medically appropriate in this scenario.
plaque_quantification_eligibility: Individual has acute or stable chest pain with no known coronary artery disease (CAD) AND the current completed and interpreted CCTA indicates intermediate risk or CAD-RADS 1, 2, or 3 AND cardiac evaluation is negative or inconclusive for acute coronary syndrome.CAD-RADS 1-3
Plaque quantification is medically necessary only under these combined conditions.
Not Medically Necessary — Coronary CTA plaque quantification
Coronary CTA plaque quantification or coronary plaque analysis using CCTA is considered not medically necessary in any of the following scenarios (any of the following):
Non-covered plaque quantification scenarios: Unstable coronary syndromes; in conjunction with invasive coronary catheterization; for screening or disease surveillance; within 30 days of a myocardial infarction; when current completed and interpreted CCTA documents Normal CCTA, CAD-RADS-0, high-grade stenosis (>70%), CAD-RADS 4, or CAD-RADS 5.within 30 days post-MI; high-grade stenosis >70%
List taken directly from policy statements.
Appropriate Uses — CT for Cardiac Structure and Morphology
CT of the heart is considered medically appropriate for evaluation of cardiac structure and morphology for any of the following when indicated:
Appropriate structural/morphologic CT indications: Cardiac vein identification for left ventricular lead placement; evaluation of pulmonary vein anatomy prior to pulmonary vein isolation (including post-ablation between 3–6 months); CT as an alternative to MRI when clinical suspicion is supported by established criteria for arrhythmogenic right ventricular dysplasia (ARVD) or suspected ARVD/ARVC.post-ablation 3-6 months
Applied when echocardiogram is inconclusive for certain structural indications.
Appropriate Uses — CT after inconclusive echocardiogram
CT of the heart is considered medically appropriate when echocardiogram was performed and is inconclusive for all of the following:
Echocardiogram prerequisite: Cardiac or pericardial mass or tumor; cardiac thrombus; pericarditis or constrictive pericarditis; complications of cardiac surgery.
Policy requires prior echocardiogram to be inconclusive for these indications.
Post-cardiac surgery complications (echocardiogram inconclusive)
Cardiac CT is considered medically appropriate when ALL of the following are met
echocardiogram inconclusive: Echocardiogram was performed and is inconclusive for complications of cardiac surgery.
Suspected ARVD/ARVC
Cardiac CT in place of MRI when clinical suspicion is supported by established criteria for ARVD/ARVC
ARVD/ARVC scenarios: Suspected ARVD or ARVC with presyncope or syncope; cardiac CT may be used when MRI is not available or is contraindicated.
LAA occlusion device assessment and surveillance
Cardiac CT in place of TEE for assessment of LAA occlusion device or thrombus
LAA device imaging timepoints: Pre-procedural evaluation; repeat imaging 45 days post-procedure (with earlier follow-up at 3–6 months if 45-day imaging shows a peri-device gap ≥5 mm or device-related thrombus); and one (1) year post-procedure.45 days; >=5 mm peri-device gap; 1 year
Follow-up schedule and peri-device gap threshold specified in policy.
Congenital heart disease indications
Cardiac CT for congenital heart disease is considered medically appropriate for ANY of the following
congenital CT indications: Coronary artery anomaly evaluation when cardiac catheterization failed to identify all coronary arteries; thoracic arteriovenous anomaly evaluation when MRI or chest CTA suggested congenital heart disease; complex adult congenital heart disease evaluation when no prior cardiac CT/MRI performed and MRI contraindicated OR when prior cardiac CT/MRI was performed ≥ 1 year ago.prior CT/MRI >= 1 year
CT Imaging for TAVR candidate assessment
Imaging considered medically appropriate for pre-TAVR evaluation when ANY of the following apply
TAVR pre-op imaging: CTA Chest, Abdomen and Pelvis; Cardiac CT to measure the aortic annulus; Coronary CTA to assess the coronary arteries or aortic annulus in lieu of invasive heart catheterization.
Post-TAVR assessment
Cardiac CT post-TAVR is considered medically appropriate for ANY of the following when TTE is indeterminate or raises concerns
Cardiac CT appropriate when TTE is indeterminate or raises concerns.
Post-TAVR medically appropriate indications
Cardiac CT post-TAVR is considered medically appropriate when ANY of the following are present:
Post-TAVR indications: TTE indeterminate or raises concerns for valve thrombosis.
Post-TAVR indications: TTE indeterminate or raises concerns for infective endocarditis.
Post-TAVR indications: TTE indeterminate or raises concerns for structural degeneration.
Pre-procedural planning: When valve-in-valve implantation or surgical re-do aortic valve replacement is being contemplated.
General coverage criteria for CCTA
Covered when clinical presentation is consistent with ischemic evaluation and CCTA technical requirements can be met
Ischemic symptoms and imaging capability: Patient has symptoms warranting ischemic evaluation (likely anginal symptoms, less likely anginal symptoms with appropriate clinical context, or anginal equivalents in patients with known CAD) AND the imaging facility can perform high‑resolution CCTA with intravenous contrast, heart-rate control, and ECG gating as needed.
See symptom definitions; anginal equivalents apply for those with prior CABG or PCI.
Guideline-based Appropriate Uses (excerpt)
Relevant guideline recommendations cited in the document include:
ACC/AHA 2021 chest pain recommendations: CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD in intermediate-risk patients with acute chest pain and no known CAD after negative/inconclusive ACS evaluation; can determine progression in known nonobstructive CAD; effective for diagnosis and risk stratification in intermediate-high risk stable chest pain; reasonable after inconclusive/abnormal stress testing; reasonable to evaluate bypass grafts or stents ≥3 mm after prior revascularization.
Source: ACC/AHA 2021 guidelines referenced in policy.
SCCT 2021 consensus: SCCT recommends CCTA for evaluation of stable coronary artery disease (native vessels, post revascularization, FFR or CT myocardial perfusion imaging), coronary anomalies, and artery evaluation prior to noncoronary cardiac surgery.
Source: SCCT 2021 referenced in policy.
ACCF/AHA historical guidance: Guidance noting CCTA might be reasonable for intermediate pretest probability patients and is not recommended for cardiovascular risk assessment in asymptomatic adults.
Source: ACCF/AHA guidance cited in policy.
Policy updates (June 18, 2026 and prior revisions)
Policy updates and criteria changes (high-level):
New criteria for prior cardiac surgery or CAD: New criteria were added specifying use of CCTA for individuals with prior history of cardiac surgeries or history of coronary artery disease.
See full policy for detailed logic.
Preoperative transplant assessment clarification: Clarification was added to the criteria for preoperative assessment for planned liver or kidney transplant patients.
See full policy for exact indications and contraindications.
Additional risk factors and indications: Additional risk factors (hyperlipidemia and history of adverse pregnancy outcomes) and an indication (chest pain with syncope) were added.
Incorporate these risk factors when applying criteria.
Coronary CTA plaque quantification:
Isolated T-wave inversion in lead III or leads V1–V2 is explicitly excluded from the policy’s new abnormal rest ECG findings criterion. When documenting a qualifying ECG change as part of an ischemic evaluation, a new T-wave inversion limited to lead III or leads V1–V2 should not be treated as sufficient evidence to meet that indication for CCTA.
If a patient with newly diagnosed congestive heart failure or cardiomyopathy has already undergone an invasive or advanced noninvasive ischemic test (cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram) since the time of diagnosis, that prior testing negates the policy indication for performing CCTA under the "newly diagnosed" criterion.
More generally, when prior diagnostic testing for ischemia (such as cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram) has been performed since the relevant diagnosis or symptom onset, the policy indicates those prior studies may preclude coverage of CCTA for the same diagnostic purpose.
Coronary CT plaque quantification or plaque analysis is not medically necessary when the clinical presentation reflects an unstable coronary syndrome. Requests for plaque quantification in the setting of unstable ischemia will be considered non‑covered and may be denied.
Additional situations where coronary CTA plaque quantification or plaque analysis is considered not medically necessary include when performed in conjunction with invasive coronary catheterization; for screening or routine disease surveillance; within 30 days of a myocardial infarction; or when the current completed and interpreted CCTA documents Normal findings, CAD-RADS 0, shows high-grade stenosis (>70%), or reports CAD-RADS 4 or 5.
For evaluation of complex adult congenital heart disease the policy requires that a prior cardiac CT or cardiac MRI not have been performed; if a cardiac CT or cardiac MRI was performed recently such that the policy’s repeat‑imaging interval is not met (1 year in applicable scenarios), the CCTA indication is not applicable and repeat CCTA is not supported.
Cardiac CT performed as routine surveillance or follow‑up after transcatheter aortic valve replacement (TAVR), including imaging ordered solely to evaluate incidental HALT/HAM (hypoattenuated leaflet thickening with or without restricted leaflet motion), is considered not medically necessary and is excluded from coverage.
Cardiac CTA is classified as investigational for any indication not specifically listed in the policy as medically appropriate. Requests for CCTA for unspecified or novel indications should be expected to be denied unless the request clearly matches a covered scenario.
When a clear non‑cardiac explanation for the patient’s symptoms is present and is the most likely cause (for example, gastroesophageal reflux disease, chest trauma, anemia, COPD, or pleurisy), cardiac ischemic evaluation with CCTA is not considered clinically indicated under this policy.
The policy follows guideline guidance that CCTA is not recommended for cardiovascular risk assessment in asymptomatic adults. CCTA should not be used as a routine screening tool for cardiovascular risk in individuals without symptoms.
HCPCS coding is not applicable in the HCPCS section of this policy; the document lists the HCPCS entry as Not Applicable for the cardiac CT/CCTA services described.
Per the policy revision history, the guidance for use of Cardiac CT in relation to TAVR was relocated; Cardiac CT for TAVR has been moved to a not medically necessary policy statement in the update dated 06/18/26. Clinicians and billing staff should follow the revised stance when assessing TAVR‑related CT requests.
This space is reserved for policy content. See the full policy for detailed criteria, thresholds, and documentation requirements referenced throughout these coverage statements and revision notes.
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).
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 left ventricular (LV) cardiac function, right ventricular (RV) structure and function and evaluation of vascular structures, if performed).
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).
Quantification and characterization or 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.
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.
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)
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 left ventricular (LV) cardiac function, right ventricular (RV) structure and function and evaluation of vascular structures, if performed)
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
Quantification and characterization or 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
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
HCPCSHCPCS
Not Applicable
No HCPCS codes listed in this section
ICD-10ICD-10
Multiple Codes
ICD-10 codes — multiple; not specified in this section
Added per policy history (code edit) - cardiac CT code
0623T
Deleted per policy history (previously listed Category III)
0624T
Deleted per policy history (previously listed Category III)
0625T
Deleted per policy history (previously listed Category III)
0626T
Deleted per policy history (previously listed Category III)
Coronary artery calcium (CAC) score — key value
Coronary artery calcium (CAC) score> 100
ContextCAC >100 cited as an indication for CCTA when patients have new/recurrent/worsening chest pain or exertional symptoms
Source notePolicy text lists 'Coronary artery calcium (CAC) score greater than 100' as qualifying criteria
Age and risk-factor threshold — key value
Age and risk-factor thresholdAge ≥ 50 years with ≥ 2 cardiovascular risk factors
Authorization, Documentation, and Denial Risk Guidance
Prior Authorization
Confirm indication matches policy before requesting prior authorization
Coronary CTA is medically appropriate only for indications listed in this policy; when requesting prior authorization, confirm the requested CCTA aligns with one of the covered clinical scenarios in the policy (e.g., new/recurrent/worsening cardiac chest pain, specified structural or preoperative indications, congenital indications, post‑TAVR concerns).
Ensure indication maps to policy language before submission.
Requests that do not match listed indications may be denied.
Prior authorization is required for CCT/CCTA to evaluate newly diagnosed congestive heart failure or cardiomyopathy only when ALL listed conditions are met: no prior history of CAD; ejection fraction <50%; low or intermediate pre‑test probability; no contraindications to CCTA; and no cardiac cath, SPECT, PET, or stress echocardiogram performed since diagnosis.
Document absence of prior CAD and EF <50%.
Clinical Context and Evidence Summary
Coronary computed tomographic angiography (CCTA) is a high‑resolution, intravenous contrast–enhanced CT examination used to noninvasively evaluate coronary artery anatomy, detect atherosclerotic plaque and stenosis, and assess graft patency or cardiac structure. The policy defines specific symptomatic and risk‑based scenarios in which CCTA is considered medically appropriate (for example, new, recurrent, or worsening cardiac‑type chest pain or exertional symptoms with qualifying features), and it references guideline statements that limit use in asymptomatic patients. CCTA may also be used as an alternative to invasive angiography or other modalities in defined situations (e.g., preoperative coronary assessment, evaluation of anomalous coronaries in younger patients, or when stress testing or echocardiography is inconclusive), and may be combined with advanced software analyses (plaque quantification or noninvasive FFR‑CT) when policy criteria are met.
Use in policyPrimary symptom definition used across indications for CCTA (new, recurrent, or worsening)
ImplicationDocument nature of symptoms (likely anginal, less likely anginal, anginal equivalents) when ordering CCTA
Anomalous coronary artery classifications — key value
Classification examplesAnomalies of origin (e.g., interarterial course between pulmonary artery and aorta), anomalies of course (myocardial bridging), anomalies of termination (coronary artery fistula)
Indication contextUsed when evaluating individuals under 40 for suspected anomalous coronary artery or for treatment planning after nondiagnostic angiography
Policy Updates and Change Log
2026-06-18off-cycle reviewLatest
Off-cycle review added new criteria for individuals with prior history of cardiac surgeries or history of coronary artery disease and clarified criteria for preoperative assessment for planned liver or kidney transplant.
2026-01-22off-cycle review
Off-cycle review added additional risk factors (hyperlipedemia and history of adverse pregnancy outcomes), added chest pain with syncope as an indication, and moved a guideline regarding Cardiac CT for TAVR to a not medically necessary policy statement.
Key ActionEnsure prior authorization and documentation show the indication aligns with policy criteria when requesting CCTA, including required prior testing and clinical risk factors.
Prior nondiagnostic coronary angiography when needed to determine course, origin, or bypass graft location for anomalies of origin, course, or termination (examples: LCA or RCA arising from pulmonary artery; interarterial course between pulmonary artery and aorta; myocardial bridging; coronary artery fistula).
Examples listed in policy.
Newly diagnosed heart failure/cardiomyopathy - criterion 5: No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis.
Re-do CABG to evaluate location of left internal mammary artery (LIMA) and/or right internal mammary artery (RIMA) prior to repeat surgery.
Left main stent surveillance: To evaluate a left main stent one time at six (6) to twelve (12) months.6-12 months
One-time evaluation.
PCI CTO planning: Pre-procedural planning for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO).
Coronary anomalies/complex congenital disease: Evaluation of coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels.
Replace invasive angiography - Takotsubo: Cardiac CTA to replace conventional invasive coronary angiography for delayed presentation or retrospective evaluation of suspected Takotsubo syndrome (stress cardiomyopathy).
New medically necessary criteria for coronary CTA plaque quantification were added.
Refer to the full policy for precise measurement thresholds and use cases.
Risk factors (examples listed)diabetes mellitus; current cigarette smoking; family history of premature CAD; hypertension; hyperlipidemia; history of adverse pregnancy outcomes
Clinical contextApplies to patients with new/recurrent/worsening chest pain or exertional symptoms when combined with risk criteria
ContextOne required criterion for CCTA in evaluation of newly diagnosed congestive heart failure or cardiomyopathy
Concurrent requirementsNo prior history of CAD; low or intermediate pre-test probability; no contraindications to CCTA; no cardiac cath/SPECT/PET/stress echo since diagnosis
Patient age for anomalous coronary evaluation — key value
Patient age thresholdUnder 40 years
IndicationsSuspected anomalous coronary artery or treatment planning when qualifying features are present (e.g., exertional syncope, exertional chest pain with normal stress test, sibling sudden death, resuscitated sudden death)
Anomaly examplesAnomalies of origin (interarterial course), anomalies of course (myocardial bridging), anomalies of termination (coronary artery fistula)
Time and stenosis thresholds — key value
Time threshold post-MIWithin 30 days of myocardial infarction (plaque quantification is not medically necessary)
Stenosis threshold (high-grade)>70% stenosis (defined as high-grade) — current CCTA showing this makes plaque quantification not medically necessary
ContextThese thresholds are denial triggers for coronary CTA plaque quantification/analysis
Peri-device gap threshold — key value
Peri-device gap threshold>= 5 mm
ContextIf 45-day LAA occlusion imaging shows a peri-device gap ≥5 mm or device‑related thrombus, an additional follow-up (usually at 3–6 months) is medically necessary before one‑year surveillance
ImplicationFailure to obtain required repeat imaging after a ≥5 mm gap may render later imaging requests unsupported
Prior cardiac CT/MRI interval — key value
Prior cardiac CT/MRI interval>= 1 year
ContextFor congenital heart disease and other indications, CCTA is considered when prior cardiac CT or MRI was performed ≥1 year ago
ImplicationRecent cardiac CT or MRI within one year may preclude repeat CCTA per policy
Stenosis / FFR thresholds for CAD classification — key value
Obstructive CAD thresholds≥40% left main stenosis; ≥50% stenosis in other major epicardial vessels; FFR ≤ 0.80; history of prior PCI or CABG
Non-obstructive CAD thresholds<40% left main; <50% other major epicardial vessels; FFR > 0.80
UseThese thresholds define obstructive vs non‑obstructive CAD for documentation and prior evidence requirements
CAD-RADS 3–5 (reference)CAD-RADS 3 = 50–69%; CAD-RADS 4 = 70–99% or ≥50% left main; CAD-RADS 5 = 100% occlusion (full definitions in policy)
RelevanceCAD-RADS categories are used to determine eligibility for plaque quantification and to identify non‑medically necessary scenarios (e.g., CAD‑RADS 0, 4, 5)
Misc coding note (blank) — key value placeholder
Note(reserved) No content provided in source for this coding/correlation note
ActionLeave blank or populate per billing team guidance if needed
ContextPlaceholder block in layout — no supporting text in policy excerpt
Document that no invasive/noninvasive ischemic testing (cardiac cath, SPECT, PET, or stress echo) has been done since diagnosis.
Prior Authorization
Specify the exact covered indication on the authorization request
When obtaining prior authorization state the specific clinical indication for the exam (for example: newly diagnosed cardiomyopathy without prior ischemic evaluation; re‑do CABG planning to assess graft patency or LIMA/RIMA location; or CTO PCI planning), because authorization should reflect the particular covered indication.
Use the precise indication text from the policy in the authorization request.
Include supporting documentation that matches the named indication.
Prior Authorization
When replacing stress test for transplant preop, document prior testing and ETT inability
If substituting CCTA for an imaging stress test in preoperative assessment for planned liver or kidney transplant, prior authorization should include documentation of prior testing status and risk: an imaging stress test within one year (unless new symptoms/ECG changes) or documentation that the patient could not perform an ETT when intermediate‑risk criteria apply.
State whether an imaging stress test was performed and its date.
If no ETT was possible, document inability to perform ETT and relevant clinical risk factors.
Prior Authorization
Authorization may be needed for CT for cardiac structure/morphology indications
Prior authorization may be required when requesting CT of the heart for structural/morphologic indications such as cardiac vein identification for LV lead placement, pulmonary vein anatomy evaluation pre‑ or post‑PVI (including 3–6 months post‑ablation), or other structural planning uses.
Identify the structural indication (e.g., LV lead planning, PVI anatomy) in the request.
Attach prior echocardiogram or other relevant imaging if required by the indication.
Prior Authorization
Prior authorization should reflect congenital and TAVR-related indications
Cardiac CT/CCTA is considered medically appropriate for the congenital indications and TAVR‑related pre‑procedural assessments listed in the policy; prior authorization workflows should reflect these specific indications when applicable.
For TAVR candidacy include CTA Chest/Abdomen/Pelvis or cardiac CT annulus measurements as indicated.
For congenital indications indicate prior imaging status (e.g., prior catheterization where coronary arteries were not identified).
Prior Authorization
Prior authorization for post‑TAVR CT only for indeterminate/concerning TTE findings
For post‑TAVR cardiac CT, prior authorization should be requested only when TTE is indeterminate or raises concerns (valve thrombosis, infective endocarditis, structural degeneration) or when valve‑in‑valve or surgical redo AVR is being contemplated; routine surveillance and evaluation of incidental HALT/HAM are not medically necessary.
Include TTE findings demonstrating indeterminate or concerning results.
Do not request CT for routine surveillance or incidental HALT/HAM as those are considered not medically necessary.
Prior Authorization
Indicate contrast, equipment capability, and any advanced CCTA analyses on authorization
Prior authorization submissions should note that CCTA involves IV contrast, high‑resolution/high‑speed CT equipment and may include advanced software analyses (automated plaque quantification or FFR‑CT), as these factors can affect medical‑necessity review.
Indicate whether IV contrast will be used and the scanner capability/heart‑rate control plan.
If requesting software‑derived analyses (plaque quantification or FFR‑CT), specify that in the authorization.
Prior Authorization
Obtain prior authorization as required for listed CPT codes (75572–75580)
Certain CPT codes for cardiac CT/CCTA and software‑derived analyses are listed in the policy (e.g., 75572, 75573, 75574, 75577, 75580) and may be subject to product‑specific coverage decisions; obtain prior authorization per payer rules for these services when required.
List the CPT code(s) for the requested service on the authorization.
Confirm coverage for the member's product before scheduling.
Billing Rule
Use policy CPT descriptions for billing; no separate prior‑auth code list stated
The policy enumerates CPT codes for cardiac CT/CCTA and software‑derived analyses but does not specify a separate authorization code list; use the policy's CPT descriptions when billing and follow payer authorization rules.
Use CPT descriptions from the policy for coding and billing.
Authorization requirements are product/payer dependent and are not tied to a distinct code list in the policy text.
Billing Rule
Account for code updates (75577 added) when obtaining authorization and billing
Prior authorization and billing workflows should account for recent code edits; code 75577 was added to the policy history and should be considered in authorization and billing processes according to the member's product and contract.
Update billing/authorization systems to include CPT 75577.
Verify product‑specific coverage for the newly listed code prior to service.
Documentation Required
Provide prior test results when symptoms persist after or tests are equivocal
CCTA is appropriate when symptoms persist after a normal stress test or when prior noninvasive testing is equivocal, borderline, abnormal, or discordant since symptom onset; document prior test results when requesting authorization.
Provide dates/results of prior stress tests or noninvasive evaluations.
If prior testing is equivocal or discordant, include that interpretation in the documentation.
Documentation Required
Document dual goals when using CCTA instead of invasive angiography after unexplained SCA
For individuals recovered from unexplained sudden cardiac arrest, CCTA may be used in place of invasive coronary angiography when both: (1) confirmation of presence/absence of ischemic heart disease and (2) exclusion of an anomalous coronary artery are required; document both goals in the authorization.
State that the study is replacing invasive angiography and document the need to confirm ischemic disease and exclude anomalous coronary anatomy.
Attach prior resuscitation details and relevant contraindications to conventional angiography if present.
Documentation Required
Document rationale when CCTA substitutes for stress imaging before class IC agents
When CCTA is used instead of stress imaging to evaluate structural heart disease before prescribing class IC antiarrhythmic agents (flecainide or propafenone), indicate this rationale and document why stress imaging was not performed.
Specify the intended medication decision (class IC agent) in the request.
Include rationale for using CCTA instead of stress imaging.
Documentation Required
Document recent imaging stress test or new symptoms/ECG changes for high‑risk surgical candidates
High‑risk surgical candidates should have an imaging stress test within one year unless new cardiac symptoms or a new ECG change have occurred; if substituting CCTA, document the timing of the last stress test or new symptoms/ECG changes to justify replacement.
Document date of last imaging stress test if within one year.
If no recent stress test, document new symptoms or ECG changes that justify CCTA.
Documentation Required
Include inconclusive echocardiogram report when requesting CT for structural indications
For structural cardiac CT indications that require prior echocardiography, the authorization should include evidence that an echocardiogram was performed and was inconclusive (e.g., for mass, thrombus, pericarditis, or post‑surgical complications).
Attach the echocardiogram report showing inconclusive findings.
State the specific structural indication that remains unresolved by echo.
Documentation Required
Document MRI contraindication/unavailability when using CT as an alternative
When echocardiogram is inconclusive or MRI is contraindicated/unavailable for suspected ARVD/ARVC or post‑operative complications, document that MRI cannot be performed and that CT is the indicated alternative.
Document MRI contraindication or unavailability.
Provide clinical criteria supporting suspicion for ARVD/ARVC or the post‑operative complication.
Step Therapy
When escalation from TTE to CT is needed, include TTE findings in the request
Escalation from an indeterminate or concerning TTE to cardiac CT is implied by the policy for post‑procedural or structural concerns; document the TTE findings that prompted escalation when requesting CT.
Include the TTE report demonstrating indeterminate or concerning findings.
Describe how CT will address the diagnostic gap left by TTE.
Note
Guidelines and trials inform but do not add step‑therapy mandates in this excerpt
Clinical trials and guideline citations are provided in the policy for context, but the policy text in the provided segments does not impose additional step‑therapy mandates beyond the listed indications and imaging prerequisites.
Do not assume additional step‑therapy requirements beyond those explicitly stated in the policy.
Use guideline recommendations as clinical context when justifying requests.
Step Therapy
No explicit step‑therapy pathway stated — follow policy criteria and payer rules
The policy excerpts provided do not describe an explicit step‑therapy pathway for CCTA; when no step therapy is stated, follow the policy's indication criteria and local payer prior authorization rules.
If uncertain, confirm with the member's product/payer whether step requirements exist.
Rely on explicit policy criteria (indications, prior test requirements) for clinical justification.
Note
Note
Documentation Required
Document basis for medical necessity (guidelines, evidence, law, contract)
Medical necessity determinations are based on evidence‑based literature, national professional guidelines, federal/state law, regulatory mandates, and the member's subscriber contract language; include relevant references or contract notes in complex cases.
Indicate guideline or evidence references when appropriate to support the request.
Document any applicable regulatory or contractual factors for the member.
Documentation Required
Include prior PCI/CABG or obstructive CAD history plus current symptoms
When requesting authorization for symptomatic patients with prior PCI/CABG or known obstructive CAD, include documentation of prior PCI/CABG or prior obstructive CAD and current symptomatic presentation (cardiac chest pain, anginal equivalents, or symptoms similar to prior ischemic episodes).
Describe current symptoms and how they relate to prior ischemic episodes.
Documentation Required
Document qualifying features when evaluating anomalous coronary arteries in <40 y/o
For individuals under age 40 being evaluated for anomalous coronary arteries, document qualifying clinical features such as exertional syncope, persistent exertional chest pain with a normal stress test, a full sibling with sudden death before age 40 or documented anomalous coronary artery, or resuscitated sudden death.
Provide family history or sibling sudden death documentation if applicable.
Attach stress test results if chest pain is exertional with normal stress test.
Documentation Required
Document clinical features suggestive of systemic vasculitis for coronary assessment
When requesting CCTA for suspected coronary involvement from systemic vasculitis, include documentation of clinical features suggestive of vasculitis (e.g., unexplained elevated inflammatory markers, constitutional symptoms, or multiple visceral infarcts without embolic etiology).
Attach lab results (ESR, CRP) and descriptions of constitutional symptoms.
Provide imaging or clinical evidence of visceral infarcts if present.
Documentation Required
Document timing of left main stent (6–12 months) for one‑time surveillance CCTA
To justify a one‑time CCTA evaluation for left main stent surveillance, document timing of prior left main stent placement to show the exam falls within the 6–12 month window specified by the policy.
Include procedure date and operative/PCI report showing left main stent placement.
State that this is a one‑time evaluation at 6–12 months post‑stent per policy.
Documentation Required
Document inability to perform ETT and prior stress test timing for transplant preop CCTA
For transplant preoperative CCTA in place of stress testing, document the patient's inability to perform an exercise treadmill test (ETT) when intermediate‑risk surgery criteria apply and include the date of the last imaging stress test if within one year.
Document inability to perform ETT and clinical risk factors that qualify for intermediate‑risk assessment.
Provide date of last imaging stress test if available.
Documentation Required
Attach inconclusive echocardiogram report when requesting CT for structural indications
When CT is requested for specific structural indications (mass, thrombus, pericarditis, post‑surgical complications), include the echocardiogram report showing it was performed and inconclusive, as this is required for cardiac CT coverage for these indications.
Attach the echocardiogram report and note the inconclusive elements.
Explain why CT is necessary to resolve the diagnostic question.
Documentation Required
Support TAVR pre‑op CT requests with specific study type and clinical rationale
For TAVR pre‑procedural imaging, documentation should support use of CTA Chest/Abdomen/Pelvis, cardiac CT annulus measurements, or coronary CTA in lieu of catheterization — include the specific study requested and the clinical rationale when submitting authorization.
Specify which TAVR‑related CT study is requested (CTA Chest/Abdomen/Pelvis, cardiac CT annulus measurement, coronary CTA).
Provide clinical justification for using CT instead of catheterization when applicable.
Documentation Required
Include prior cath/CCTA showing stenosis or FFR thresholds when documenting CAD status
When documenting obstructive or non‑obstructive CAD to support CCTA use or downstream decisions, include prior heart catheterization or CCTA results showing the stenosis thresholds or FFR values cited in policy (e.g., ≥40% left main, ≥50% other major epicardial vessels, or FFR ≤0.80) or history of prior PCI/CABG.
Attach prior cath or CCTA reports with percent stenosis or FFR values.
If prior revascularization present, include procedure reports (PCI/CABG).
Documentation Required
Describe ischemic symptom type and prior CABG/PCI; document premedication/HR control
Document the nature of ischemic‑evaluation symptoms (likely anginal, less likely anginal, or anginal equivalents) and any prior history of CABG or PCI when ordering CCTA; also document premedication or heart‑rate control if used for image acquisition.
Describe symptom pattern consistent with policy definitions (e.g., exertional chest pain relieved by rest/nitro).
Note any heart‑rate control measures (beta‑blocker use) used for image quality.
Documentation Required
Reference FDA device/contrast regulatory information when relevant
Refer to the FDA Medical Device website for regulatory status and recall information relevant to CT hardware and contrast agents used for cardiac CTA; include device/contrast regulatory notes if relevant to the authorization or safety review.
If device or contrast safety concerns are relevant, reference FDA device/recall information.
Include device model or contrast agent details if requested by payer.
Billing Rule
Use policy CPT descriptions for billing and confirm product coverage
Use CPT codes and descriptions listed in the policy when billing cardiac CT/CCTA and derived analyses; note that additional payer documentation requirements may apply and coverage can vary by product.
Code the service using the CPT codes enumerated (e.g., 75572–75580 as applicable).
Confirm product‑level coverage before billing; include any required documentation with claims.
Documentation Required
Verify member product coverage and include supporting documentation
Demonstrate that the member's product covers the requested service and include documentation that policy criteria are met when required; services may be denied if the product does not cover the service even when policy criteria are satisfied.
Verify member product benefit for the requested CT service before authorization.
Include product coverage confirmation and policy‑criteria documentation in the request.
Denial Risk
Denial risk if requested indication does not match listed covered scenarios
Requests for CCTA that do not match the policy's listed clinical indications (new, recurrent, or worsening cardiac chest pain or the other specified scenarios) are at risk for denial; ensure the submitted indication and documentation directly align with a covered scenario.
Map the clinical presentation to the exact policy indication.
If the patient’s symptoms have a likely non‑cardiac explanation, do not request CCTA for ischemic evaluation.
Denial Risk
Prior advanced testing since diagnosis may preclude CCTA for newly diagnosed HF/cardiomyopathy
If cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since diagnosis of heart failure/cardiomyopathy, that prior testing negates the policy criterion for using CCTA in newly diagnosed disease and may lead to denial.
Include dates and results of any post‑diagnosis invasive or advanced noninvasive ischemic testing.
If such testing exists since diagnosis, do not submit CCTA under the newly diagnosed HF/cardiomyopathy indication.
Denial Risk
Plaque quantification requests may be denied in multiple excluded scenarios
Requests for coronary CTA plaque quantification or plaque analysis will be denied as not medically necessary when performed for unstable coronary syndromes; in conjunction with invasive coronary catheterization; for screening or surveillance; within 30 days post‑MI; or when current CCTA is normal, CAD‑RADS‑0, shows high‑grade stenosis (>70%), CAD‑RADS 4, or CAD‑RADS 5.
Do not request plaque quantification for unstable coronary syndromes or within 30 days of MI.
If current CCTA documents high‑grade stenosis, CAD‑RADS 4/5, or normal CCTA/CAD‑RADS‑0, plaque quantification is not medically necessary.
Denial Risk
Failure to obtain recommended follow‑up after 45‑day LAA imaging may risk later denials
If a 45‑day post‑LAA occlusion imaging study documents a peri‑device gap ≥5 mm or device‑related thrombus and a follow‑up imaging interval was indicated (usually 3–6 months), failure to obtain the recommended repeat imaging may render later imaging requests unsupported.
Provide prior 45‑day imaging results and any follow‑up imaging performed.
If 45‑day imaging showed peri‑device gap ≥5 mm or thrombus, include documentation of subsequent imaging at the recommended interval.
Denial Risk
Routine post‑TAVR surveillance and incidental HALT/HAM evaluations are not covered
Cardiac CT for routine surveillance or follow‑up post‑TAVR, including evaluation of incidental HALT/HAM, is considered not medically necessary and requests for such routine surveillance may be denied.
Do not submit routine surveillance CT post‑TAVR or CT to evaluate incidental HALT/HAM.
If CT is requested post‑TAVR, document specific TTE concerns that meet the policy criteria.
Denial Risk
Document non‑cardiac explanations for symptoms; these may justify denying CCTA
If the patient's symptoms have a non‑cardiac explanation that is the most likely cause (e.g., GERD, trauma, anemia, COPD, pleurisy), document that diagnosis; such cases may support denial of cardiac ischemic‑evaluation testing.
Include evidence of the non‑cardiac diagnosis if applicable.
If non‑cardiac cause is most likely, do not pursue CCTA for ischemic evaluation.
Billing Rule
Verify product‑level code coverage — services may be denied if product excludes them
Coverage and denial decisions for codes may vary by member product; verify whether the member's product covers the CPT code(s) before submitting authorization because services may be denied if the product does not cover them.
Confirm product‑level code coverage prior to authorization.
If product excludes the service, the policy criteria do not apply and the request may be denied.
Billing Rule
Code lists may change — verify current CPT/Category III updates with payer
AMA/CMS code updates may occur more frequently than policy revisions; the policy's code list may not be exhaustive — verify current CPT/Category III updates and payer code lists when preparing authorization and billing.
Check for recent CPT or Category III code changes beyond the policy text.
Confirm with payer if additional or replacement codes should be used.
Prior Authorization
Product coverage determines applicability of policy criteria — confirm before submitting
If the member's product does not cover a specific service, medical policy criteria do not apply and the request may be denied; ensure authorization and documentation reflect the member's contract and product rules.
Confirm whether the member's commercial, Medicaid, or Medicare product covers the requested CT service.
Document product coverage confirmation in the authorization when required.
Prior Authorization
Where policy is silent on authorization triggers, follow criteria and contact payer if unclear
When no specific authorization triggers or denial conditions are stated in policy text for a scenario, rely on the explicit covered‑indication criteria and payer rules; if uncertain, contact the payer for pre‑authorization guidance.
Use explicit policy criteria to justify requests when authorization triggers are not defined.
Contact payer for clarification when policy text is silent on authorization triggers.
Note
Note
Clinical features prompting evaluationSyncopal episodes during strenuous activities, exertional chest pain with normal stress test, full sibling sudden death, resuscitated sudden death
Re-do CABG assessment — key value
Re-do CABG assessment usesAssess bypass graft patency; evaluate location of LIMA and/or RIMA prior to repeat bypass surgery
ApplicationCCTA indicated as part of planning for repeat CABG to define graft anatomy and conduit locations
NotePolicy explicitly lists these as covered indications for re-do CABG
Replacement of invasive coronary angiography — key value
Replacement scenariosCCTA may replace invasive coronary angiography for delayed presentation or retrospective evaluation of suspected Takotsubo syndrome
ContextPolicy permits substitution of CCTA for ICA in specific retrospective/delayed presentations
ImplicationUse CCTA when clinical scenario meets listed criteria to avoid invasive angiography
FFR-CT — key value definition
FFR-CT definitionNoninvasive fractional flow reserve derived from CT to further assess coronary lesions of uncertain physiologic significance seen on CCTA
Use caseConsidered medically appropriate to further assess lesions when physiologic significance is uncertain on recent coronary CTA
Technology noteExample FDA‑approved software: HeartFlow FFRCT discussed in policy background
Coronary CT plaque quantification — key value definition
Plaque quantification definitionMeasurement of coronary plaque burden using CCTA data for individuals with acute or stable chest pain and no known CAD when specified risk/CAD‑RADS criteria are met
EligibilityMedically necessary when current CCTA indicates intermediate risk or CAD‑RADS 1–3 and chest pain present with no known CAD
ExclusionsNot medically necessary for unstable coronary syndromes, within 30 days post‑MI, or when CCTA shows CAD‑RADS 0, 4, 5, or high‑grade stenosis (>70%)
CAD-RADS — key value reference
CAD-RADS referenceCAD-RADS is a classification of percent luminal diameter stenosis on CCTA used in the policy (definitions CAD‑RADS 0–5 provided)
Policy useCAD‑RADS categories determine eligibility for plaque quantification and identify non‑medically necessary scenarios
High-grade stenosis — definition (>70%)
High‑grade stenosis definition> 70%
Policy implicationPresence of high‑grade stenosis on current CCTA makes plaque quantification not medically necessary
Related CAD‑RADSCorresponds to CAD‑RADS 4 (70–99%) and is a denial trigger for plaque analysis
ARVD/ARVC — key value definition
ARVD/ARVC definition/contextArrhythmogenic right ventricular dysplasia (ARVD)/arrhythmogenic ventricular cardiomyopathy (ARVC): clinical suspicion supported by established criteria where CT may be used in place of MRI
Use caseCCTA may substitute for MRI when MRI is contraindicated or unavailable for suspected ARVD/ARVC
ExamplesIncludes suspected ARVD or ARVC with presyncope or syncope
HALT / HAM — key value definition
HALT/HAM definitionHypoattenuated leaflet thickening (HALT) with or without restricted leaflet motion; also known as hypoattenuation affecting motion (HAM)
Policy stanceRoutine surveillance or follow‑up cardiac CT post‑TAVR for incidental HALT/HAM is not medically necessary
Clinical implicationIncidental HALT/HAM should not by itself trigger routine CCTA surveillance per policy
Fractional flow reserve (FFR) — key value definition
FFR definitionFractional flow reserve (FFR) is the ratio between maximal blood flow in a narrowed artery and maximal blood flow in a normal artery; FFR‑CT is a noninvasive estimate derived from CCTA
Clinical useFFR (invasive) ≤0.80 indicates physiologically significant stenosis; FFR‑CT used when lesion significance is uncertain on CCTA
Coding linkageNoninvasive FFR from CCTA corresponds to CPT 75580 (software‑derived analysis)
CAD‑RADS detailed categories — key value
CAD‑RADS detailed categoriesCAD‑RADS 0: 0%; 1: 1–24%; 2: 25–49%; 3: 50–69%; 4: 70–99% or ≥50% left main; 5: 100% occlusion
Clinical implicationCAD‑RADS categories used to guide plaque quantification eligibility and clinical management decisions
Policy usagePolicy explicitly cites CAD‑RADS categories as part of medically necessary and not medically necessary statements
CPT 75577Quantification and characterization of coronary atherosclerotic plaque from CCTA data (software‑derived analysis) with interpretation and report
CPT 75580Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of CCTA dataset with interpretation and report
Use noteThese codes describe augmentative software analyses of CCTA data and are listed in policy coding section
Quantification and characterization of coronary atherosclerotic plaque (CPT 75577) — key value
CPT 75577 descriptionQuantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, derived from augmentative software analysis of the data set from a coronary CTA, with interpretation and report
Coding notePolicy history notes 75577 was added to CPT list (see revision history)
Clinical useUsed for software‑derived plaque quantification when medically indicated per policy criteria
Noninvasive FFR from CCTA (CPT 75580) — key value
CPT 75580 descriptionNoninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of CCTA dataset, with interpretation and report
Clinical useFFR‑CT processing code for noninvasive physiologic assessment following CCTA when lesion significance uncertain
Coding contextListed among policy CPT codes for cardiac CT/CCTA and software‑derived analyses
CCTA / Cardiac CT — general definition
CCTA / Cardiac CT definitionCoronary computed tomographic angiography and cardiac CT: noninvasive imaging using IV contrast and high‑resolution, high‑speed CT to evaluate coronary arteries, grafts, stents, cardiac structure and function
Technical requirementsRequires IV contrast, high‑resolution CT equipment, ECG gating, heart‑rate control (often beta‑blocker to target ~60–65 bpm) and thin section acquisition (<1 mm)
ApplicationsEvaluation of obstructive CAD, graft patency, stent patency, coronary anomalies, coronary aneurysm, and functional cardiac assessment; may substitute for invasive angiography in specified scenarios
2025-12-29
code edit
Policy code edits: CPT code 75577 was added and Category III codes 0623T–0626T were deleted; policy intent unchanged.
2025-09-18annual review
Annual review updated criteria for CCTA and added new medically necessary criteria for coronary CTA plaque quantification.
2024-11-21revision entry
Listed as a prior policy history date in the revision history (entry present in policy history timeline).
2023-12-21revision entry
Listed as a prior policy history date in the revision history (entry present in policy history timeline).
2023-04-20revision entry
Listed as a prior policy history date in the revision history (entry present in policy history timeline).