Cardiac Multislice Computed Tomography Criteria

Cardiac Multislice Computed Tomography utilizes advanced temporal and spatial resolution to image the heart, major thoracic vessels, and coronary arteries.  In select situations, Coronary Computerized Tomography Angiography can reasonably rule out significant coronary artery disease and can achieve the degree of diagnostic accuracy required to replace conventional coronary angiography.

Cardiac Multislice Computed Tomography is covered when any one of the following criteria is met:

1. As an alternative to invasive angiography following an equivocal or indeterminate stress test.
2. As a measurement of CAC (Coronary Artery Calcium) scoring for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10-20%, 10 year risk) by the Framingham risk score and modified Framingham/ATP risk scores.
3. For imaging-suspected congenital abnormalities of the coronary circulation
4. For the preoperative assessment of patients undergoing repeat coronary bypass surgery
5. For the assessment of coronary or pulmonary venous anatomy
   • This application is indicated for pre-surgical planning.  Visualization of the coronary venous anatomy can be useful for a cardiologist who needs to place a pacemaker in the lateral coronary vein in order to resynchronize cardiac contractions in patients with heart failure.
   • It is also used for the visualization of pulmonary vein anatomy prior to ablation procedures for recurrent atrial fibrillation.
6. Low to moderate risk patient with atypical symptoms, where repeat stress testing is negative, and more definitive information without undergoing invasive testing is required
7. Evaluation of left atrium and pulmonary vein anatomy and function prior to cardiac ablation.
8. For preoperative and postoperative left atrial appendage closure in patients where TEE is inadequate or contraindicated.

Cardiac Multislice Computed Tomography is not covered for asymptomatic screening.

Approved:  3/07

Reviewed: 1/09, 3/10, 2/11, 1/12, 1/13, 3/14, 2/15, 1/16, 1/17, 3/18, 1/19, 2/20

Revised: 2/08, 1/16, 3/18