MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Coronary Angiography for Known or Suspected Coronary Artery Disease

Number 2.02.507

Effective Date October 1, 2013

Revision Date(s) N/A

Replaces N/A

Policy

Coronary artery disease, known or suspected

Coronary angiography for known or suspected coronary artery disease may be considered medically necessary only when applicable MCG™ (formerly Milliman Care Guidelines®) criteria for “Coronary artery disease, known or suspected” are met. (See Policy Guidelines for modifications to MCG™ criteria.)

Coronary angiography for known or suspected coronary artery disease is considered not medically necessary when there is no documented clinical indication as defined by MCG™ criteria for “Coronary artery disease, known or suspected” that meets the medically necessary criteria for this procedure. (See Policy Guidelines for modifications to MCG™ criteria.)

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

2.02.508

Non-Urgent Percutaneous Coronary Intervention/Angioplasty

6.01.03

Computed Tomography to Detect Coronary Artery Calcification

6.01.43

Contrast-Enhanced Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation

Policy Guidelines

MCG™ (formerly Milliman Care Guidelines®) criteria for Cardiac Angiography are used as a tool to guide medical necessity determinations and utilization management decisions, per licensed agreement, for coronary angiography. The related MCG™ ORG is: Cardiac Angiography (ACG: A-0001 [AC]) (1).

Modifications to MCG

The following are modifications to MCG™:

  • Coronary artery disease, known or suspected, as indicated by 1 or more of the following:
  • Evidence of high risk based on noninvasive testing, as indicated by 1 or more of the following
  • Deletion of this criterion: Coronary artery calcium score greater than 400 Agatston units
  • Coronary artery disease, known or suspected, as indicated by 1 or more of the following:
  • Deletion of this criterion and two bullets below: Occupation of patient directly involves safety of others (e.g., bus driver, pilot, firefighter) and 1 or more of the following:
  • Deletion: Abnormal results on noninvasive testing
  • Deletion: Risk factors for coronary artery disease

*NOTE: The MCG™ manuals are proprietary and cannot be published and/or distributed. However, on an individual member basis, Premera can share a copy of the specific criteria document used to make a utilization management decision. If you would like a copy of these criteria, you may request a copy by calling the Customer Service number on the member’s health plan card.

The Plan reserves the right to review and modify the MCG™ (formerly Milliman Care Guidelines) criteria or Customized Guidelines at any time.

Description

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.

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

Scope

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

N/A

Rationale

Coronary artery calcium scoring

Calcium scores have been investigated as a technique for detecting coronary artery calcification, both as a diagnostic technique in symptomatic patients to rule out an atherosclerotic etiology of symptoms or, in asymptomatic patients, as an adjunctive method for risk stratification for coronary artery disease.

The rationale for measuring calcium in coronary arteries is that it measures coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not be causing ischemia or symptoms. Such a measure may be correlated with the presence of critical coronary stenoses or serve as a measure of the patient’s proclivity toward atherosclerosis and future coronary disease. Thus, it could serve as a variable to be used in a risk assessment calculation for the purposes of determining appropriate preventive treatment in asymptomatic patients. Alternatively, in other clinical scenarios, it might help determine whether there is atherosclerotic etiology or component to the presenting clinical problem in symptomatic patients, thus helping to direct further workup for the clinical problem. In this second scenario, a calcium score of zero usually indicates that the patient’s clinical problem is unlikely to be due to atherosclerosis and that other etiologies should be more strongly considered. In neither case does the test actually determine a specific diagnosis. Most clinical studies have examined the use of coronary calcium for its potential use in estimating the risk of future coronary heart disease events.

Coronary calcium levels can be expressed in many ways. The most common method is the Agatston score, which is a weighted summed total of calcified coronary artery area observed on computed tomography (CT). This value can be expressed as an absolute number, commonly ranging from 0 to 400. These values can be translated into age and sex-specific percentile values. Different imaging methods and protocols will produce different values based on the specific algorithm used to create the score, but the correlation between any 2 methods appears to be high, and scores from one method can be translated into scores from a different method.

Coronary calcium for coronary disease risk stratification

Many prospective studies have shown evidence for predictive capacity of calcium scores in addition to assessment of traditional risk factors. In a study of 1,029 asymptomatic adults with at least 1 coronary risk factor, Greenland et al. (2) showed that a calcium score of greater than 300 predicted increased risk of cardiac events within Framingham risk categories. A study by Arad et al. (3) showed similar findings in a population-based sample of 1,293 subjects who had both traditional risk factors and calcium scores evaluated at baseline. A study by Taylor et al. (4) studied the association of the Framingham risk score and calcium scores in a young military population (mean age 43 years). Although only 9 acute coronary events occurred, calcium scores were associated with risk of events while controlling for the risk score. LaMonte et al. (5) also analyzed the association of calcium scores and coronary heart disease (CHD) events in 10,746 adults. In this study, coronary risk factors were self-reported. During a mean follow-up of 3.5 years, 81 CHD events occurred. Similar to the other studies, the relationship between calcium scores and CHD events remained after adjustment for other risk factors. Other studies (6-8) show similar findings. Additional studies have defined how the incorporation of calcium scores into risk scores changes risk prediction. In a study by Polonsky et al., (9) incorporation of calcium score into a risk model resulted in more subjects (77% vs. 66%) being classified in either high-risk or low-risk categories. The subjects who were reclassified to high risk had similar risk of CHD events as those who were originally classified as high risk. A study by Elias-Smale et al. (10) showed similar findings; reclassification of subjects occurred most substantially in the intermediate risk group (5-10% 5-year risk) where 56% of persons were reclassified.

A growing body of literature now addresses the relationship of traditional risk factors, calcium scores, and risk of CHD. Current treatment guidelines for coronary disease prevention recommend specific treatment based on prediction of coronary disease risk. The cited studies enrolled different populations, assessed different traditional risk factors, and assessed different coronary disease outcomes. Different calcium score cutoffs were analyzed in the studies. Given the variation in the studies, the magnitude of increased risk conferred by a given calcium score is still uncertain. The results of the study by Greenland et al. (2) would suggest that a high calcium score, as defined as a score greater than 300, does not change risk appreciably for those with Framingham risk scores less than 10% or greater than 20%. Given that there is no direct evidence that risk stratification using calcium scores in addition to traditional risk assessment improves patient outcomes, a consensus approach that integrates existing evidence with a modeling approach to predicting patient outcomes would aid in determining whether calcium scoring is of value.

Coronary calcium for ruling out atherosclerotic etiology of disease in symptomatic patients

In certain clinical situations such as patients presenting with chest pain or other symptoms, it is uncertain whether the symptoms are potentially due to CHD. Coronary calcium measurement has been proposed as a method that can rule out CHD in certain patients if the coronary calcium value is zero. Since coronary disease can only very rarely occur in the absence of coronary calcium, the presence of any coronary calcium can be a sensitive but not specific test for coronary disease. False positives occur because the calcium may not be causing ischemia or symptoms. The absence of any coronary calcium can be a specific test for the absence of coronary disease and direct the diagnostic workup toward other causes of the patient’s symptoms. In this context, coronary calcium measurement is not used to make a positive diagnosis of any kind but as a diagnostic “filter” used to rule out an atherosclerotic cause for the patient’s symptoms.

For example, in a study by Laudon et al. in the emergency department setting, 51% (133/263) patients with chest pain and low-to-moderate probability of CAD had calcium scores of zero. (10) One of these patients was found to actually have coronary disease. The others were presumed to not have coronary disease, and it is claimed that these patients could have been safely discharged from the emergency department. However, the study is not rigorous in its methods regarding the alternative workup of potential coronary artery disease in the emergency department or in the long-term follow-up of patients.

Evidence regarding the use of coronary calcium scores in the assessment of symptomatic patients has been reviewed in a 2007 clinical consensus co-written by the American College of Cardiology Foundation (ACCF) and the American Hospital Association (AHA). (11) Calcium scores have similar sensitivity and specificity to other tests such as exercise single-photon emission computed tomography (SPECT) and stress echocardiography for the diagnosis of anatomic obstructive CHD. It is difficult to determine the validity of these diagnostic performance characteristics given the possible referral and confirmation biases. If the performance of the reference standard for coronary disease such as angiography is based upon the results of the diagnostic tests under study, diagnostic test characteristics are biased.

Impact on cardiac risk factor profiles

There have been 2 randomized, controlled trials (RCTs) of the impact of electron-beam computed tomography (EBCT) on cardiac risk factors. O’Malley et al. (12) randomized 450 subjects to receive EBCT or not and assessed outcomes 1 year later for change in Framingham Risk Score. Thus, EBCT was to be used as a guide to refine risk in patients and possibly provide motivation for behavioral change. The study was not powered for clinical endpoints. EBCT did not produce any benefits in terms of a difference in Framingham risk score at 1 year.

An RCT was published in 2011 evaluating the impact of computed tomography (CT) scanning for coronary artery calcium on cardiac risk factors. (13) A total of 2,137 healthy individuals were randomized to CT scanning or no CT scanning and followed for 4 years. At baseline, both groups received 1 session of risk factor counseling by a nurse practitioner. The primary outcome was change in 12 different cardiac risk profile measures, including blood pressure (BP), lipid and glucose levels, weight, exercise, and the Framingham risk score. At the 4-year follow-up, there was differential dropout among the groups, with 88.2% of follow-up in the scan group versus 81.9% in the no-scan group. Results demonstrated differences in 4 of the 12 risk factor measurements between groups: systolic BP, low-density lipoprotein (LDL), waist circumference, and mean Framingham risk score.

This trial highlights the potential benefit of coronary artery calcium screening in modifying cardiac risk profile but is not definitive in demonstrating improved outcomes. Limitations of this study include different intensity of interventions between groups and differential dropout. It is possible that the small differences reported in the trial were the result of bias from these methodologic limitations. In addition, this trial does not compare the impact of other types of risk factor intervention, most notably more intensive risk factor counseling. Finally, the generalizability of the findings is uncertain given that this was a volunteer population that may have been highly motivated for change.

Future research needs

The current research mainly establishes that coronary artery calcium screening improves risk prediction for coronary artery disease. The 2011 randomized controlled trial (RCT) suggests that scanning may favorably impact cardiac risk profiles but is not sufficient in itself to demonstrate improved outcomes. In order to demonstrate that use of calcium scores improves the efficiency or accuracy of the diagnostic workup of symptomatic patients, rigorous studies that define exactly how coronary calcium scores are used in combination with other tests in the triage of patients would be necessary. Study designs need to explicitly evaluate diagnostic strategies that compare one strategy which uses calcium scores to an alternative which does not use calcium scores. Ideally, patient outcomes and resource utilization would need to be prospectively evaluated.

Practice Guidelines and Position Statements

In 2006, the American Heart Association (AHA) issued a scientific statement (14) on the use of cardiac CT. Most of the document reviewed the utility of calcium scoring for the use of determining prognosis and diagnosis. In addition to reviewing a large body of evidence regarding calcium scoring, clinical recommendations were also offered. No indications received a class I recommendation, i.e., evidence and/or agreement that the procedure is useful and effective. Several indications received a class IIb recommendation, which means that there is conflicting evidence and/or a divergence of opinion regarding usefulness or efficacy. The “b” qualifier indicates usefulness/efficacy is less well established. The indications that received an IIb recommendation were:

  • Patients with chest pain with equivocal or normal ECGs [electrocardiograms] and negative cardiac enzymes
  • Determining the etiology of cardiomyopathy
  • Symptomatic patients, in the setting of equivocal treadmill or functional tests
  • Asymptomatic patients with intermediate (e.g., 10–20% 10-year risk) risk of CAD [coronary artery disease]

Four indications received a class III recommendation, which means that there is evidence that the procedure or treatment is not useful or possibly harmful. These indications were:

  • Low-risk (<10% 10-year risk) and high-risk (>20% 10-year risk) asymptomatic patients
  • Establishing the presence of obstructive disease for revascularization in asymptomatic persons
  • Serial imaging for assessment of progression of coronary calcification
  • Hybrid nuclear and CT imaging

The 2006 AHA scientific statement (14) also cited several other studies showing an association between calcium scores and CAD events after adjustment for traditional risk factors. The report recognized that despite growing evidence that calcium scores are an independent predictor of CAD, studies have not demonstrated improved clinical outcomes as a result of calcium score screening. This scientific statement reflected these uncertainties in the utility of calcium scoring in their clinical guideline statements.

A 2007 clinical consensus document co-written by the American College of Cardiology Foundation (ACCF) and the AHA (11) reviewed much of the same evidence as the 2006 AHA scientific statement. It should be noted that this type of consensus document represents the best attempt of the ACCF and AHA to inform clinical practice where rigorous evidence is not yet available. Thus formal grading of evidence and classification of clinical recommendations are not reported in this type of document. This document essentially concludes that the indications receiving an IIb recommendation in the 2006 scientific statement “may be reasonable.…” Recommendations from the 2010 ACCF/AHA Guidelines are noted below.

In 2009, the U.S. Preventive Services Task Force (USPSTF) issued recommendations regarding the use of nontraditional or novel risk factors in assessing CHD risk in asymptomatic persons. (15,16) Calcium score was 1 of 9 risk factors considered in the report. They concluded that the current evidence is insufficient to assess the balance of benefits and harms of using any of the nontraditional risk factors studied to assess risk of coronary disease in asymptomatic persons. In their focused review of 5 studies, which they judged to have valid study designs, they found wide variation in the estimates of the risk ratio for higher calcium scores. Higher quality studies had lower relative risks for a given difference in calcium score. This review disagrees with the ACCF/AHA 2007 clinical consensus document (11) regarding the effect of calcium scores on reclassifying risk of coronary disease. Rather than the 4 studies that the ACCF/AHA document claims provides information about reclassification, the USPSTF report only finds one such study.

Recommendations on calcium scoring from the 2010 ACCF/AHA Guidelines (17) are as follows:

Class IIa

Measurement of CAC [coronary artery calcification] is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk). (Level of Evidence: B)

Class IIb

Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low to intermediate risk (6% to 10% 10-year risk). (Level of Evidence: B)

Class III: No Benefit

Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment. (Level of Evidence: B

In November 2012, ACCF/AHA/ACP/AATS/PCNA/SCAI/STS issued new recommendation on calcium scoring. The 2012 guidelines (21) are as follows:

Class IIb

For patients with a low to intermediate pretest probability of obstructive IHD, non-contrast cardiac computed tomography to determine the coronary artery calcium score may be considered.

(Level of Evidence: C)

A systematic review by Ferket et al. (19) identified 14 guidelines that evaluated diagnostic imaging for asymptomatic coronary artery disease, which included those reviewed above, and additional guidelines from New Zealand and Canada. Ten of the guidelines addressed use of calcium score as a method to improve coronary risk assessment. Four guidelines concluded that there was sufficient evidence for consideration of its use, and 1 guideline recommended for its use. The only group of patients for whom its use was recommended was that of intermediate-risk patients. For subjects at low risk or high risk, guidelines were unanimous in not advocating calcium scoring.

In 2012, Hayes, Inc. published a technology assessment on calcium scoring for asymptomatic adults. (20) They found that the scoring added incremental predictive value over traditional risk factor assessments such as the Framingham Risk Score, particularly among asymptomatic adults at “intermediate” risk of a cardiac event. However, they said it was not yet known whether the addition of calcium scoring to standard risk factors assessment will improve patient-important outcomes such as cardiac events, and they concluded that it had potential but unproved benefit. In regard to asymptomatic adults at “low or high risk” for coronary artery disease, their analysis of the scientific literature led them to conclude that it had no proven benefit at this time due to sparsity of studies evaluation coronary artery disease in this population. Hayes also expressed concern over CT-induced radiation exposure as the biggest safety concern in relation to calcium scoring.

Summary

There is extensive evidence on the predictive value of coronary artery calcium screening for cardiovascular disease, and this evidence demonstrates that scanning has only incremental predictive accuracy above traditional risk factor measurement. High-quality evidence is lacking comparing the use of coronary artery calcium screening to other methods of enhanced risk prediction, and as a result, there is uncertainty as to which methods are preferred in specific populations. Limited evidence from clinical trials suggests that scanning may lead to improved risk factor profiles, but this finding has not been consistent and methodologic limitations preclude definitive conclusions on this question.

Evidence-based guideline statements regarding calcium score measurement give, at best, a reserved recommendation in favor of the use of EBCT and recognize the incomplete evidence base that supports those recommendations. Review of several guidelines shows disagreement regarding the utility of calcium score measurement. The USPSTF review highlights the inconsistency of the relative risk of coronary disease associated with calcium scores, thus making risk estimates based on it imprecise. Because of the lack of high-quality evidence demonstrating improved outcomes and the lack of strong recommendations from authoritative sources, coronary artery calcium scores are not considered definitive evidence of high risk.

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 defined by MCG, 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

  1. MCG™ - 17th Edition (formerly Milliman Care Guidelines®): Ambulatory Care, Cardiac Angiography (ACG:A-0001). Available online at: http://careweb.careguidelines.com/ed17/. Last accessed April 23, 2013.
  2. Greenland P, LaBree L, Azen SP et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004; 291(2):210-5.
  3. Arad Y, Goodman KJ, Roth M et al. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol 2005; 46(1):158-65.
  4. Taylor AJ, Bindeman J, Feuerstein I et al. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol 2005; 46(5):807-14.
  5. LaMonte MJ, FitzGerald SJ, Church TS et al. Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women. Am J Epidemiol 2005; 162(5):421-9.
  6. Lakoski SG, Greenland P, Wong ND et al. Coronary artery calcium scores and risk for cardiovascular events in women classified as "low risk" based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med 2007; 167(22):2437-42.
  7. Budoff MJ, Shaw LJ, Liu ST et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007; 49(18):1860-70.
  8. Elkeles RS, Godsland IF, Feher MD et al. Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study. Eur Heart J 2008; 29(18):2244-51.
  9. Polonsky TS, McClelland RL, Jorgensen NW et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA 2010; 303(16):1610-6.
  10. Laudon DA, Behrenbeck TR, Wood CM et al. Computed tomographic coronary artery calcium assessment for evaluating chest pain in the emergency department: long-term outcome of a prospective blind study. Mayo Clin Proc 2010; 85(4):314-22.
  11. Greenland P, Bonow RO, Brundage BH et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2007; 49(3):378-402.
  12. O’Malley PG, Feuerstein IM, Taylor AJ. Impact of electron beam tomography, with or without case management, on motivation, behavioral change, and cardiovascular risk profile: a randomized controlled trial. JAMA 2003; 289(17):2215-23.
  13. Rozanski A, Gransar H, Shaw LJ et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing. J Am Coll Cardiol 2011; 57(15):1622-32.
  14. Budoff MJ, Achenbach S, Blumenthal RS et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006; 114(16):1761-91. Available online at: http://circ.ahajournals.org/cgi/content/full/114/16/1761. Last accessed June 7, 2013.
  15. Helfand M, Buckley DI, Freeman M et al. Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151(7):496-507.
  16. U.S. Preventive Services Task Force. Using nontraditional risk factors in coronary heart disease risk assessment: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151(7):474-82.
  17. 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.
  18. Blue Cross Blue Shield Association. Computed Tomography to Detect Coronary Artery Calcification. Medical Policy Reference Manual, Policy 6.01.03. Last review July 2012.
  19. 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.
  20. Hayes, Inc. Hayes Medical Technology Directory Report. Coronary Artery Calcium Scoring to Assess the Risk of Coronary Artery Disease in Asymptomatic Adults. Lansdale, PA: Hayes, Inc.; June, 2012.
  21. 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 June 7, 2013.

Coding

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

ICD-9 Diagnosis

394.0

Mitral stenosis

 

394.2

With insufficiency

 

394.9

Other and unspecified mitral valve diseases

 

395.0

Rheumatic aortic (valve) obstruction

 

395.1

Rheumatic aortic incompetence, regurgitation

 

395.2

Rheumatic aortic stenosis with incompetence or regurgitation

 

395.9

Rheumatic aortic (valve) disease

 

396.0

Atypical aortic (valve) stenosis; Mitral and aortic (valve) obstruction (rheumatic)

 

396.1

Mitral valve stenosis and aortic valve insufficiency

 

396.2

Mitral valve insufficiency and aortic valve stenosis

 

396.8

Stenosis and insufficiency of mitral or aortic valve with stenosis or insufficiency, or both, of the other valve

 

410.0

Acute myocardial infarction of anterolateral wall

 

410.1

Of other anterior wall

 

410.2

Of inferolateral wall

 

410.3

Of interoposterior wall

 

410.4

Of other inferior wall

 

410.5

Of other lateral wall

 

410.6

True posterior wall infarction

 

410.7

Subendocardial infarction

 

410.8

Of other specified sites

 

411.1

Intermediate coronary syndrome

 

413.1

Variant angina pectoris

 

413.9

Other and unspecified angina pectoris

 

416.0

Primary pulmonary hypertension

 

416.9

Chronic pulmonary heart disease, unspecified

 

420.0

Acute pericarditis in diseases classified elsewhere

 

420.9

Other and unspecified acute pericarditis

 

425.0

Endomyocardial fibrosis

 

425.1

Hypertropic cardiomyopathy

 

425.2

Obscure cardiomyopathy of Africa

 

425.3

Endocardial fibroelastosis

 

425.4

Other primary cardiomyopathies

 

425.5

Alcoholic cardiomyopathy

 

425.7

Nutritional and metabolic cardiomyopathy

 

425.8

Cardiomyopathy in other diseases classified elsewhere

 

425.9

Secondary cardiomyopathy, inspecified

 

428.0

Congestive heart failure

 

428.1

Left heart failure

 

428.2

Systolic heart failure

 

428.3

Diastolic heart failure

 

428.4

Combined systolic and diastolic heart failure

 

428.9

Unspecified heart failure

 

446.1

Acute febrile mucocutaneous lymph node syndrome (MCLS)

 

745.2

Tetralogy of Fallot

 

745.4

Ventricular septal defect

 

746.7

Hypoplastic left heart syndrome

 

746.8

Other specified anomalies of heart

 

746.84

Obstructive anomalies of heart, not elsewhere classified

 

746.9

Unspecified anomaly of heart

 

747.1

Coarctation of aorta

 

747.2

Other anomalies of aorta

 

747.3

Anomalies of pulmonary artery

ICD-9 Procedure

   

ICD-10-CM
(effective 10/01/14)

A1884

Tuberculosis of heart

 

I43

Cardiomyopathy in diseases classified elsewhere

 

I05.0

Rheumatic mitral stenosis

 

I05.2

Rheumatic mitral stenosis with insufficiency

 

I05.8

Other rheumatic mitral valve diseases

 

I05.9

Rheumatic mitral valve disease, unspecified

 

I06.0

Rheumatic aortic stenosis

 

I06.1

Rheumatic aortic insufficiency

 

I06.2

Rheumatic aortic stenosis with insufficiency

 

I06.8

Other rheumatic aortic valve diseases

 

I06.9

Rheumatic aortic valve disease, unspecified

 

I08.0

Rheumatic disorders of both mitral and aortic valves

 

I08.8

Other rheumatic multiple valve diseases

 

I20.0

Unstable angina

 

I20.1

Angina pectoris with documented spasm

 

I20.9

Angina pectoris, unspecified

 

I21.01

ST elevation (STEMI) myocardial infarction involving left main coronary artery

 

I21.02

ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

 

I21.09

ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

 

I21.11

ST elevation (STEMI) myocardial infarction involving right coronary artery

 

I21.19

ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

 

I21.21

ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

 

I21.29

ST elevation (STEMI) myocardial infarction involving other sites

 

I21.4

Non-ST elevation (NSTEMI) myocardial infarction

 

I22.0

Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

 

I22.1

ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

 

I22.2

Subsequent non-ST elevation (NSTEMI) myocardial infarction

 

I22.8

Subsequent ST elevation (STEMI) myocardial infarction of other sites

 

I25.19

Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris

 

I25.110

Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

 

I25.111

Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm

 

I25.118

Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris

 

I25.119

Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

 

I25.700

Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris

 

I25.701

Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm

 

I25.708

Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris

 

I25.709

Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris

 

I25.710

Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris

 

I25.711

Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm

 

I25.718

Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris

 

I25.720

Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris

 

I25.721

Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm

 

I25.728

Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris

 

I25.729

Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris

 

I25.730

Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris

 

I25.731

Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm

 

I25.738

Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris

 

I25.739

Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris

 

I25.750

Atherosclerosis of native coronary artery of transplanted heart with unstable angina

 

I25.751

Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm

 

I25.758

Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

 

I25.759

Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris

 

I25.760

Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina

 

I25.761

Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm

 

I25.768

Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris

 

I25.769

Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris

 

I25.790

Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris

 

I25.791

Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm

 

I25.798

Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris

 

I25.799

Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris

 

I27.0

Primary pulmonary hypertension

 

I27.81

Cor pulmonale (chronic)

 

I27.9

Pulmonary heart disease, unspecified

 

I30.8

Other forms of acute pericarditis

 

I30.9

Acute pericarditis, unspecified

 

I42.1

Obstructive hypertrophic cardiomyopathy

 

I42.2

Other hypertrophic cardiomyopathy

 

I42.3

Endomyocardial (eosinophilic) disease

 

I42.4

Endocardial fibroelastosis

 

I42.5

Other restrictive cardiomyopathy

 

I42.6

Alcoholic cardiomyopathy

 

I42.7

Cardiomyopathy due to drug and external agent

 

I42.8

Other cardiomyopathies

 

I42.9

Cardiomyopathy, unspecified

 

I50.1

Left ventricular failure

 

I50.9

Heart failure, unspecified

 

I50.20

specified systolic (congestive) heart failure

 

I50.21

Acute systolic (congestive) heart failure

 

I50.22

Chronic systolic (congestive) heart failure

 

I50.23

Acute on chronic systolic (congestive) heart failure

 

I50.30

Unspecified diastolic (congestive) heart failure

 

I50.31

Acute diastolic (congestive) heart failure

 

I50.32

Chronic diastolic (congestive) heart failure

 

I50.33

Acute on chronic diastolic (congestive) heart failure

 

I50.40

Unspecified combined systolic (congestive) and diastolic (congestive) heart failure

 

I50.41

Acute combined systolic (congestive) and diastolic (congestive) heart failure

 

I50.42

Chronic combined systolic (congestive) and diastolic (congestive) heart failure

 

I50.43

Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

 

M30.3

Mucocutaneous lymph node syndrome [Kawasaki]

 

Q20.9

Congenital malformation of cardiac chambers and connections, unspecified

 

Q21.0

Ventricular septal defect

 

Q21.3

Tetralogy of Fallot

 

Q23.4

Hypoplastic left heart syndrome

 

Q24.8

Other specified congenital malformations of heart

 

Q24.9

Congenital malformation of heart, unspecified

 

Q25.1

Coarctation of aorta

 

Q25.4

Other congenital malformations of aorta

 

Q25.5

Atresia of pulmonary artery

 

Q25.71

Coarctation of pulmonary artery

Appendix

N/A

History

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


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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