Commercial

Medical Policy

Notification

Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)

Notification Issued Date:

This policy is effective as of 08/14/2023.

New medical policy 09.00.58 has been created to communicate the Company's coverage position and criteria for Coronary Artery Calcium (CAC) Testing using Computed Tomography (CT).

This policy only applies to members for whom AmeriHealth Administrators serves as the claims administrator and whose group has not enrolled in the Carelon Medical Benefits Management program. For those groups who have been given the option to enroll in the Carelon Medical Benefits Management program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

Title:

Coronary Artery Calcium (CAC) Testing Using Computed Tomography (AmeriHealth Administrators)

Policy #:

09.00.58

Policy

This policy only applies to members for whom AmeriHealth Administrators serves as the claims administrator and whose group has not enrolled in the Carelon Medical Benefits Management program. For those groups who have been given the option to enroll in the Carelon Medical Benefits Management program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

MEDICALLY NECESSARY

Coronary artery calcium (CAC)

testing using computed tomography (CT) is considered medically necessary and, therefore, covered to assist with decisions regarding management of hypercholesterolemia when ALL of the following criteria are met:

No known atheromatous vascular disease
Not diabetic
Age ≥40 years and ≤75 years
Low-density lipoprotein (LDL) cholesterol ≥70 mg/dL and ≤190 mg/dL
10-year risk (using atherosclerotic cardiovascular disease [ASCVD] Pooled Cohort Equations) ≥5% and ≤20%
Individual does not have ANY of the following:

Family history of premature ASCVD

Persistently elevated low-density lipoprotein (≥160 mg/dL)

Persistently elevated triglyceride (>175 mg/dL)

Metabolic syndrome

Chronic kidney disease (estimated glomerular filtration rate [eGFR] 15-59 mL/min/1.73 m²)

Chronic inflammatory condition

History of menopause before age 40 years

History of preeclampsia

High-risk race/ethnicity (e.g., South Asian ancestry)

Markers associated with increased risk of ASCVD (if measured):

Elevated high-sensitivity C-reactive protein (≥2.0 mg/L)

Elevated lipoprotein(a) (>50 mg/dL)

Apolipoprotein B >130 mg/dL

Ankle-brachial index <0.9

EXPERIMENTAL/INVESTIGATIONAL

All other uses for CAC testing using CT are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, coronary artery calcium (CAC) testing using computed tomography (CT) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Services that are experimental/investigational are benefit contract exclusions for all products of the Company.

Description

Coronary artery calcium (CAC) testing uses computed tomography (CT) scanning to detect and assess the extent of atherosclerosis and quantifies the findings using a scoring system. CAC testing has emerged as a widely available tool for stratifying cardiovascular risk, predicting outcomes, and guiding preventive therapy in asymptomatic individuals.

CAC is most commonly quantified using the

Agatston method, which is a weighted summed total of calcified coronary artery area observed on CT. This value can be expressed as an absolute number, commonly ranging from 0 (low risk) to 400 (high risk). These values can be translated into age- and sex-specific percentile values. A number of studies have used the following definitions to relate the CAC score to coronary plaque burden:

0 Agatston units: No identifiable disease
1-99 Agatston units: Mild disease
100-399 Agatston units: Moderate disease
≥ 400 Agatston units: Severe disease

ASCVD POOLED COHORT EQUATION

Quantitative evaluation of coronary artery calcification to assist with decisions regarding the management of hypercholesterolemia includes risk assessment using the ASCVD Pooled Cohort Equation. The purpose of the pooled cohort equation is to estimate the risk of ASCVD within a 10-year period and/or lifetime risk for ASCVD among individuals without ASCVD. The American College of Cardiology's ASCVD Risk Estimator is available on the ACC website at: ASCVD Risk Estimator (acc.org).

CLINICAL PRACTICE GUIDELINES

Current clinical practice guidelines recommend selective use of CAC for guiding treatment decisions for primary prevention of ASCVD in individuals at borderline or intermediate risk.

In 2021, the European Society of Cardiology published a guideline on cardiovascular disease prevention in clinical practice. The guideline, developed in collaboration with several other additional societies, provides support for CAC testing among those with cardiovascular disease risk near decision thresholds. They support the use of a CAC score to increase or decrease a previously calculated cardiovascular disease risk score, as appropriate.

In 2021, the Canadian Cardiovascular Society published a guideline for the management of dyslipidemia for the prevention of cardiovascular disease in adults. In the guidelines, the following recommendations are provided:

CAC screening using computed tomography imaging might be considered for asymptomatic adults 40 years of age or older and at intermediate risk (FRS 10%-20%) for whom treatment decisions are uncertain
CAC screening using computed tomography imaging should not be undertaken for: (1) high-risk individuals; (2) patients receiving statin treatment; or (3) most asymptomatic, low-risk adults

The American College of Cardiology and American Heart Association (2018) Clinical Practice Guidelines on the Management of Blood Cholesterol state, "When risk status is uncertain, a coronary artery calcium (CAC) score is an option to facilitate decision making in adults 40 to 75 years of age." The guidelines further note, "One purpose of CAC scoring is to reclassify risk identification of patients who will potentially benefit from statin therapy. This is especially useful when the clinician and patient are uncertain whether to start a statin. Indeed, the most important recent observation has been the finding that a CAC score of 0 indicates a low ASCVD risk for the subsequent 10 years. Thus, measurement of CAC potentially allows a clinician to withhold statin therapy in patients showing 0 CAC."

The American College of Cardiology and American Heart Association (2019) Guideline on the Primary Prevention of Cardiovascular Disease is in line with the blood cholesterol guideline stating that adults (40-75 years of age) who are being evaluated for cardiovascular disease prevention should initially undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation with a clinician-patient risk discussion before starting pharmacological therapy. The guideline also notes that assessing for other risk-enhancing factors can help guide decision making "about preventive interventions in select individuals, as can CAC scanning." The guideline specifically states the following recommendation regarding assessment of cardiovascular risk and CAC:

In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk) or selected adults at borderline risk (5% to <7.5% 10-year ASCVD risk), if risk-based decisions for preventive interventions remain uncertain, it is reasonable to measure a CAC score to guide clinician-patient risk discussion [Class (Strength) of Recommendation: IIa; Level (Quality) of Evidence: B-NR]. A IIa class of recommendation is of moderate strength based on moderate quality nonrandomized studies.

The American Heart Association and the American College of Cardiology (2019) issued a special report on the use of risk assessment tools to guide decision-making in the primary prevention of ASCVD. This report includes an algorithm of clinical approaches to incorporate CAC measurement in risk assessment for borderline- and intermediate-risk patients:

"For borderline-risk (10-year risk 5% to <7.5%) and intermediate-risk (7.5% to <20%) patients who are undecided regarding statin therapy, or when there is clinical uncertainty regarding the net benefit, consider the value of additional testing with measurement of CAC. If CAC is measured, interpret results as follows:

a. CAC score of 0 indicates that a borderline- or intermediate-risk individual is reclassified to a 10-y event rate lower than predicted, and below the threshold for benefit from a statin. Consider avoiding or postponing statin therapy unless there is a strong family history of premature ASCVD, history of diabetes mellitus, or heavy cigarette smoking. Consider repeat CAC measurement in 5 years if patient remains at borderline or intermediate risk.

b. CAC score 1 to 99 and <75th percentile for age/sex/race/ethnicity indicates that there is subclinical atherosclerosis present. This may be sufficient information to consider initiating statin therapy, especially in younger individuals, but does not indicate substantial reclassification of the 10-y risk estimate. Consider patient preferences and, if statin decision is postponed, consider repeat CAC scoring in 5 years.

c. CAC score 100 or >75th percentile for age/sex/race/ethnicity indicates that the individual is reclassified to a higher event rate than predicted, that is above the threshold for statin benefit. Statin therapy is more likely to provide benefit for such patients."

References

Agatston AS, Janowitz WR, Hildner FJ et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Misspelled Word Coll Cardiol. 1990;15(4):827-832.

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646.

Costanzo MR, Dipchand A, Starling R, et al. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914-956.

Department of Veterans Affairs Department of Defense VA/DoD. VA/DoD Clinical Practice Guideline for the Management of Dyslipidemia for Cardiovascular Risk Reduction. Washington, DC: Department of Veterans Affairs Department of Defense; 2020. p. 127.

Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Misspelled Word Engl J Med. 2008;358(13):1336-1345.

DiBiase L, Fahmy TS, Wazni OM, et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Misspelled Word Coll Cardiol. 2006;48(12):2493-2499.

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: a report of the ACCF/AHA task force on practice guidelines. Circulation. 2012;126(25):e354-e471.

Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary. J Am Misspelled Word Coll Cardiol. 2010;56(25):2182-2199.

Greenland P, Blaha MJ, Budoff MJ et al. Coronary calcium score and cardiovascular risk. J Am Coll Cardiol. 2018;72:434-447.

Greenland P, Bonow RO, Brundage BH, et al. ACC/ 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. J Am Misspelled Word Coll Cardiol. 2007;49(3):378-402.

Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/ Misspelled Word APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082-e1143.

Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;78(22):e187-e285.

Higgins CB, de Roos A. MRI and CT of the Cardiovascular System. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Misspelled Word Coll Cardiol. 2010; 55(14):1509-1544.

Kim KP, Einstein AJ, Berrington de Gonzalez A. Coronary artery calcification screening–estimated radiation dose and cancer risk. Arch Intern Med. 2009;169(13):1188-1194.

Kramer CM, Villines TC. Up to Date. [UpToDate Web site]. 08/23/2022. Available at: http://www.uptodate.com/home/index.html [via subscription only]. Accessed March 5, 2025.

Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Circulation. 2019;139(25):e1162-e1177.

Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease. Circulation. 2005;111(5);682-696.

Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR Appropriate Utilization of Cardiovascular Imaging in Heart Failure: A Joint Report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol. 2013;61(21):2207-2231.

Pearson GJ, Misspelled Word Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults. Can J Cardiol. 2021;37(8):1129-1150.

Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Misspelled Word Eur Heart J. 2021;42(34):3227-3337. [Published correction appears in Eur Heart J. 2022 Nov 7;43(42):4468].

Coding

CPT Procedure Code Number(s)

75571

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

E78.00 Pure hypercholesterolemia, unspecified

E78.01 Familial hypercholesterolemia

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 09.00.58:

04/30/2025	This policy has been reviewed and reissued to communicate the Company's continuing position on coronary artery calcium (CAC) testing using computed tomography (CT).

04/17/2024	This policy has been reissued in accordance with the Company's annual review process.
08/14/2023	This policy is effective as of 08/14/2023. New medical policy 09.00.58 has been created to communicate the Company's coverage position and criteria for Coronary Artery Calcium (CAC) Testing using Computed Tomography (CT). This policy only applies to members for whom AmeriHealth Administrators serves as the claims administrator and whose group has not enrolled in the Carelon Medical Benefits Management program. For those groups who have been given the option to enroll in the Carelon Medical Benefits Management program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

04/17/2024

This policy has been reissued in accordance with the Company's annual review process.

08/14/2023

This policy is effective as of 08/14/2023.

New medical policy 09.00.58 has been created to communicate the Company's coverage position and criteria for Coronary Artery Calcium (CAC) Testing using Computed Tomography (CT).

This policy only applies to members for whom AmeriHealth Administrators serves as the claims administrator and whose group has not enrolled in the Carelon Medical Benefits Management program. For those groups who have been given the option to enroll in the Carelon Medical Benefits Management program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

Version Effective Date:

8/14/2023

Version Issued Date:

8/14/2023

Version Reissued Date:

4/30/2025