MEDICAL POLICY

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CODING
APPENDIX
HISTORY

Coronary Angiography for Known or Suspected Coronary Artery Disease

Number 2.02.507

Effective Date December 22, 2014

Revision Date(s) 12/22/14; 10/13/14; 08/11/14

Replaces N/A

Policy

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Coronary artery disease, known or suspected

Coronary angiography for known or suspected coronary artery disease may be considered medically necessary only for the following conditions when criteria are met:

  • Angina in any of the following situation:
  • Recurrent angina within 9 months of percutaneous coronary intervention.
  • Canadian Cardiovascular Society class I or II or New York Heart Association (NYHA) I or II (see Policy Guidelines) angina and intolerance of or failure to respond to medical treatment.
  • Canadian Cardiovascular Society class III or IV or NYHA III or IV angina that improves to class I or II on medical treatment.
  • Canadian Cardiovascular Society class III or IV or NYHA or III or IV angina despite optimal medical treatment.
  • Non-invasive testing shows finding suggestive of high risk for underlying coronary artery disease, as indicated by any of the following:
  • Echocardiographic wall motion abnormality involving greater than 2 segments
  • High-risk Duke Treadmill Score (less than or equal to minus 11) (see Guidelines)
  • Left ventricular ejection fraction 35% or less at rest
  • Stress electrocardiogram findings of ST-segment elevation, ventricular arrhythmia, or at least 2 mm of ST-segment depression
  • Stress-induced large perfusion defect or multiple perfusion defects of moderate size
  • Stress-induced left ventricular dysfunction,
  • Other evidence of high risk on myocardial perfusion imaging, as indicated by 1 or more of the following:
  • Perfusion defect characterized by large fixed perfusion defect, resting perfusion defect or stress-induced single moderate defect
  • Possible left ventricular dysfunction or global ischemia, characterized by increased lung uptake of radioisotope, left ventricular enlargement or transient ischemic dilatation of left ventricle:
  • After myocardial infarction, for risk-stratification when the following are present:
  • Clinically significant heart failure during hospital course
  • Ischemia at low level of exercise on noninvasive testing
  • Left ventricular ejection fraction 45% or less, and patient unable to undergo noninvasive testing
  • Ischemia recurrent (by clinical or noninvasive testing) within 12 months of coronary artery bypass graft
  • Pericarditis (acute), suspected, when signs and symptoms, troponin levels, and pattern of ST elevation cannot definitively rule out acute infarction
  • Prinzmetal (variant) angina, suspected
  • Patient surviving prior cardiac arrest or ventricular tachycardia
  • Risk assessment needed, prior to high-risk non-cardiac surgery, for a patient with disability or illness that precludes non-invasive testing.
  • Suspected stent thrombosis, either abrupt closure or subacute, following percutaneous coronary intervention
  • Unstable angina or non-ST-elevation myocardial infarction, and high or intermediate risk for adverse outcome, as indicated by any of the following: elevated troponin levels, ischemia related heart failure, hemodynamic or electrical instability, LVEF less than 40%, suspected or confirmed new ST segment depression, prior PCI in past 6 months or prior CABG, sustained ventricular tachycardia, angina or ischemia at rest or low activity.
  • Repeat evaluation of specific area or structure with same imaging modality, as indicated by 1 or more of the following:
  • Change in clinical status (e.g., worsening symptoms or new associated symptoms)
  • Need for re-imaging either prior to or after performance of invasive procedure
  • Need for interval reassessment that may impact treatment plan

Coronary angiography for known or suspected coronary artery disease is considered not medically necessary when criteria listed above are not met.

Coronary Artery Calcium Scoring

Coronary angiography for suspected coronary artery disease based upon results of calcium scoring is considered investigational. (See Related Policies)

NOTE: Coronary angiography for congenital heart disease, heart failure, hypertrophic cardiomyopathy, Kawasaki disease, pulmonary artery extrinsic compressions of left main coronary artery and valvular disease may be considered medically necessary and does not require medical review.

Related Policies

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2.02.508

Percutaneous Coronary Intervention/Angioplasty, Non-Urgent

Policy Guidelines

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The Canadian Cardiovascular Society (CCS) grading of angina, sometimes referred to as the CCS Functional Classification of Angina, is commonly used for the classification of severity of angina. The New York Heart Association Functional Classification of heart failure uses a similar scale:

Canadian Cardiovascular Society Functional Classification of Angina:

New York Heart Association (NYHA) Functional Classification

Functional Capacity

Objective Assessment

Class I. Ordinary physical activity does not cause angina, such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation;

Class I. Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

A. No objective evidence of cardiovascular disease.

Class II. Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress or only during the few hours after awakening. Walking more than two blocks on level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions;

Class II. Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

B. Objective evidence of minimal cardiovascular disease.

Class III. Marked limitation of ordinary physical activity. Walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace;

Class III. Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

C. Objective evidence of moderately severe cardiovascular disease.

Class IV. Inability to carry on a physical activity without discomfort – angina syndrome may be present at rest.

Class IV. Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

D. Objective evidence of severe cardiovascular disease.

Duke Treadmill Score

The Duke Treadmill Score incorporates exercise duration, the magnitude of ST segment deviation, and exercise-induced angina; it identifies patients with a high probability of severe coronary artery disease (triple vessel or left main coronary artery disease) at angiography and with a higher mortality risk. A low-risk score is +5 or greater, a moderate-risk score is between +5 and -11, and a high-risk score is -11 or less. These correspond to 5-year mortality of 3%, 10%, and 35%, respectively.

Description

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Cardiac angiography is an invasive procedure that includes fluoroscopy after injection of contrast material via catheter into the great vessels, chambers, and coronary vessels of the heart, as well as venous and arterial bypass grafts or other arterial conduits such as the mammary arteries. In addition to demonstrating areas of impeded, regurgitant, or otherwise abnormal blood flow, cardiac angiography with right heart catheterization or left ventriculography enables quantitative assessment of myocardial function, such as left ventricular ejection fraction, cardiac output, or degree of shunting. It also enables quantitative assessment of coronary blood flow.

If a blockage is found, a percutaneous coronary intervention (PCI) such as angioplasty may be done to open the blockage. This may be done during the same procedure or at a later time. If there are many blockages or blockages in certain areas, a coronary artery bypass may be indicated.

Risks of coronary angiography include cardiac tamponade, arrhythmias, injury to a catheterized artery, low blood pressure, allergic reaction to contrast dye, excessive bleeding, kidney damage, stroke or heart attack.

Coronary angiography refers specifically to the imaging of the coronary arteries to investigate coronary artery disease.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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N/A

Rationale

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For coronary artery disease, cardiac angiography may be indicated for evaluation of stable angina when symptoms cannot be medically controlled, are disabling, and when interventional treatment has been proposed as the next form of therapy. Qayyum and colleagues performed a systematic review to evaluate whether routine invasive strategy improves cardiovascular outcomes more than a selective invasive strategies for acute coronary syndrome. They evaluated 10 trials with a total of 10,648 patients and found that a routine invasive strategy cannot be proven to reduce deaths or nonfatal myocardial infarction.

Its use is discouraged in patients who have mild angina that is responsive to medication, with no evidence of ischemia on noninvasive testing. One major study cited is the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial which revealed no significant differences in the primary end point of all-cause mortality or nonfatal myocardial infarction [MI] or major secondary end points (composites of death/MI/stroke; hospitalization for acute coronary syndromes [ACSs]) during a median 4.6-year follow-up in 2,287 patients with stable coronary artery disease randomized to optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI). There were no significant differences between treatment arms for the composite of cardiac death or MI or in any of the major prespecified composite cardiovascular events during long-term follow-up, even after excluding periprocedural MI as an outcome of interest. Overall, cause-specific cardiovascular outcomes paralleled closely the primary and secondary composite outcomes of the trial as a whole. Compared with an initial management strategy of OMT alone, addition of PCI did not decrease the incidence of major cardiovascular outcomes including cardiac death or the composite of cardiac death/MI/ACS/stroke in patients with stable coronary artery disease.

The National Institute for Health and Care Excellence (NICE) recommends coronary angiography for patients with stable angina only when symptoms are not satisfactorily controlled with optimal medical treatment.

Specialty society guidelines recommend cardiac angiography for risk assessment in patients with stable ischemic heart disease in whom clinical characteristics and noninvasive testing results suggest a high likelihood of severe disease. For example, cardiac angiography is indicated when noninvasive imaging suggests the possibility of left main coronary artery stenosis or severe multivessel disease, or to guide percutaneous interventions.

The 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease lists the following indications for coronary angiography:

3.3.1. Coronary Angiography as an Initial Testing Strategy to Assess Risk: Recommendations

Class I (Should be performed)

  • Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk. (Level of Evidence: B – Single RCT or nonrandomized studies)
  • Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment. (Level of Evidence: B – Single RCT or nonrandomized studies))

3.3.2. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing: Recommendations

Class I (Should be performed)

  • Coronary arteriography is recommended for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk. (Level of Evidence: C – Consensus opinion, case studies or standard of care)

Class IIa (It is reasonable to perform)

  • Coronary angiography is reasonable to further assess risk in patients with SIHD who have depressed LV function (EF <50%) and moderate risk criteria on noninvasive testing with demonstrable ischemia (Level of Evidence: C - Consensus opinion, case studies or standard of care)
  • Coronary angiography is reasonable to further assess risk in patients with SIHD and inconclusive prognostic information after noninvasive testing or in patients for whom noninvasive testing is contraindicated or inadequate. (Level of Evidence: C - Consensus opinion, case studies or standard of care)
  • Coronary angiography for risk assessment is reasonable for patients with SIHD who have unsatisfactory quality of life due to angina, have preserved LV function (EF >50%), and have intermediate risk criteria on noninvasive testing. (Level of Evidence: C - Consensus opinion, case studies or standard of care)

Class III: (No Benefit)

  • Coronary angiography for risk assessment is not recommended in patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences. (Level of Evidence: B – Single RCT or nonrandomized studies)
  • Coronary angiography is not recommended to further assess risk in patients with SIHD who have preserved LV function (EF >50%) and low-risk criteria on noninvasive testing. (Level of Evidence: B – single RCT or nonrandomized studies)
  • Coronary angiography is not recommended to assess risk in patients who are at low risk according to clinical criteria and who have not undergone noninvasive risk testing. (Level of Evidence: C - Consensus opinion, case studies or standard of care)
  • Coronary angiography is not recommended to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing. (Level of Evidence: C - Consensus opinion, case studies or standard of care)

The 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease specifies a Class I recommendation for coronary angiography as useful in patients with presumed stable ischemic heart disease who have unacceptable ischemic symptoms despite guideline-directed medical treatment and who are amenable to, and candidates for, coronary revascularization.

The ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death suggest it may be the only diagnostic tool available for a patient unable to have exercise treadmill testing or stress imaging due to intolerance to pharmacologic stress or other technical reasons (e.g., obesity, severe pulmonary disease). It also is indicated in patients resuscitated from cardiac arrest or premonitory death rhythms, such as polymorphic ventricular tachycardia or sustained ventricular tachycardia.

Several different risk scoring systems and clinical prediction tools (such as SYNTAX and ACUITY) have been created to help differentiate patients who are likely to have significant obstructive disease on coronary angiography from those who are not, as well as to help determine optimal revascularization strategy and clinical outcomes. Specialty society guidelines state that calculation of the Society of Thoracic Surgeons (STS) and SYNTAX scores is reasonable in patients who have unprotected left main coronary artery lesions and complex coronary artery disease.

Occupation of patient that involves safety of others

Abnormal results on noninvasive testing help determine cardiac risk regardless of occupation. Indications for proceeding directly to coronary angiography, without non-invasive risk stratifying studies, do not change based on occupation. Factors such as age or sedentary lifestyle alone, in absence of other diagnoses listed in the policy statement; do not convey risk sufficient to proceed directly with coronary angiography. Thus the occupation of the patient, coupled with a factor such as sedentary lifestyle, does not, by itself, convey risk and coronary angiography would be considered not medically necessary.

References

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  1. Qayyum R, Khalid MR, Adomaityte J, Papadakos SP, Messineo FC. Systematic review: comparing routine and selective invasive strategies for the acute coronary syndrome. Annals of Internal Medicine 2008;148(3):186-96.
  2. Hemingway H, et al. Appropriateness criteria for coronary angiography in angina: reliability and validity. Annals of Internal Medicine 2008;149(4):221-31.
  3. Greenland P, Alpert JS, Beller GA et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010; 56(25):e50-103.
  4. Ferket BS, Genders TS, Colkesen EB et al. Systematic review of guidelines on imaging of asymptomatic coronary artery disease. J Am Coll Cardiol. 2011; 57(15):1591-600.
  5. Taylor CM, et al. A proposed clinical model for efficient utilization of invasive coronary angiography. American Journal of Cardiology 2010;106(4):457-62.
  6. Brener SJ, Prasad AJ, Abdula R, Sacchi TJ. Relationship between the angiographically derived SYNTAX score and outcomes in high-risk patients undergoing percutaneous coronary intervention. Journal of Invasive Cardiology 2011;23(2):66-9.
  7. Capodanno D, Di Salvo ME, Cincotta G, Miano M, Tamburino C, Tamburino C. Usefulness of the SYNTAX score for predicting clinical outcome after percutaneous coronary intervention of unprotected left main coronary artery disease. Circulation. Cardiovascular Interventions 2009;2(4):302-8.
  8. Palmerini T, et al. Comparison of clinical and angiographic prognostic risk scores in patients with acute coronary syndromes: Analysis from the Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial. American Heart Journal 2012;163(3):383-91.
  9. Levine GN, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124(23):e574-651.
  10. Hillis LD, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:e652-735.
  11. Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006;114(10):e385-484.
  12. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):3097-137. Last access July 10, 2014.
  13. Jneid H, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012;126(7):875-910.
  14. Fihn SD, Blankenship AC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American
  15. College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2014;Jul 28. pii: CIR.0000000000000095. [Epub ahead of print]. Accessed Aug. 2, 2014.
  16. MedlinePlus. Coronary Angiography. http://www.nlm.nih.gov/medlineplus/ency/article/003876.htm. Last access July 31, 2014.
  17. Fang JC, O'Gara PT. The history and physical examination: an evidence-based approach. In: Bonow RO, Mann DL, Zipes DP, Libby P, Braunwald E, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011:107-25.
  18. Chaitman BR. Exercise stress testing. In: Bonow RO, Mann DL, Zipes DP, Libby P, Braunwald E, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011:168-99.
  19. National Institute for Health and Care Excellence. Management of stable angina. NICE Guidelines [CG126]. Published July 2011. http://www.nice.org.uk/guidance/cg126/chapter/guidance. Last access Aug. 2, 2014.
  20. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256.

Coding

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Codes

Number

Description

CPT

93454

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;

 

93455

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

 

93456

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

 

93457

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

 

93458

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

 

93459

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

 

93460

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

 

93461

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Appendix

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N/A

History

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Date

Reason

06/10/13

New policy. Add to Cardiology section. This policy is approved with a 90-day hold for provider notification and will be effective on October 1, 2013.

08/15/13

Update Related Policies. Change title to policy 2.02.508.

10/17/13

Update Related Policies. Change title to policy 2.02.508

10/13/14

Annual Review. Policy extensively re-written. Policy statements reorganized but intent is unchanged. Policy updated with literature search. Reference to using MCG as a tool to guide determinations is removed. References added. Diagnosis codes (both ICD-9 and ICD-10) removed from the policy.

12/22/14

Interim Review. Reference #1 removed. Related Policies 6.01.03 and 6.01.43 archived and removed.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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