| Contractor Name |
State(s) |
Indications of Coverage |
Link to Policy |
| Alabama, Blue Cross and Blue Shield |
AL |
Contrast-enhanced computed tomographic angiography for coronary artery evaluation does not meet Blue Cross and Blue Shield of Alabama's medical criteria for coverage and is considered investigational. |
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| Arkansas Blue Cross and Blue Shield |
AK |
Multi detector computed tomography (MDCT) provides advanced spatial and temporal resolution of the heart and allows imaging of the major vessels of the chest, including the coronary arteries. This new technology lacks evidence based indications, but indirect evidence, using diagnostic performance data, decision models, and an expert consensu approach validates the following current indications. Future revisions to these indications will occur as evidence based studies become available. (See link for covered indications.) |
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| California, Wellpoint Health Networks (Blue Cross) |
CA |
The use of electron beam computed tomography (EBCT), helical CT or multislice spiral (also known as multi-row detector) CT (MSCT) is considered investigational/not medically necessary |
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| Anthem Blue Cross and Blue Shield |
CO, CT, IN, KY, ME, MO, NV, NH, OH, VA, WI |
Computed tomography angiography is considered investigational/not medically necessary for the evaluation of coronary arteries, including, but not limited to, the following: Screening for coronary artery disease (CAD), either in asymptomatic subjects or as part of a preoperative evaluation; Diagnosis of CAD, in patients with acute or non-acute symptoms, or after a coronary intervention; Delineation of a coronary artery anatomy or anomaly. Computed tomography angiography is considered investigational/not medically necessary as a technique to evaluate cardiac function. |
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| District of Columbia, CareFirst Blue Cross Blue Shield |
DC |
Computed tomographic angiography (CTA) for coronary artery disease is considered experimental / investigational as it does not meet TEC criteria #2-5. |
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| Florida, Blue Cross and Blue Shield |
FL |
Computed tomographic angiography (CTA), multislice spiral computed tomography (MSCT), and multidetector row computed tomography (MDCT) is considered investigational for the following: screening for coronary artery disease (CAD); coronary artery evaluation; detection and diagnosis of coronary artery disease (CAD); coronary artery bypass graft patency evaluation; coronary artery aneurysm evaluation; AND delineation of congenital coronary artery anomaly. There is no scientific evidence to permit conclusion concerning the effect of computed tomographic angiography on health outcomes. |
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| Georgia, Blue Cross and Blue Shield |
GA |
Computed tomography angiography is considered investigational/not medically necessary for the evaluation of coronary arteries, including, but not limited to, the following: Screening for coronary artery disease (CAD), either in asymptomatic subjects or as part of a preoperative evaluation; Diagnosis of CAD, in patients with acute or non-acute symptoms, or after a coronary intervention; Delineation of a coronary artery anatomy or anomaly. Computed tomography angiography is considered investigational/not medically necessary as a technique to evaluate cardiac function. |
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| Regence BlueShield |
ID, OR, UT, WA |
Contrast-enhanced computed tomographic angiography for coronary artery evaluation is considered investigational. |
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| Iowa, Wellmark Blue Cross and Blue Shield |
IA |
Contrast-enhanced computed tomographic angiography (CTA) is considered investigational for the evaluation of coronary arteries, including, but not limited to the following indications: Screening for coronary artery disease (CAD), either in asymptomatic patients or as part of a preoperative evaluation; Diagnosis of CAD, in patients with acute or non-acute symptoms, or after a coronary intervention; Delineation of a coronary artery anatomy of anomaly. Contrast-enhanced computed tomography angiography is considered investigational as a technique to evaluate cardiac function. |
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| Illinois, Blue Cross and Blue Shield |
IL |
Spiral (Helical) Computed Tomography (Spiral CT, Helical CT) with or without contrast media, when imaging the heart, is considered experimental, investigational, or unproven as: a detection of the risk of obstruction in coronary or cerebral arteries (including calcification) as a screening examination for asymptomatic patients, and a replacement of traditional tests (i.e., stress test[s], coronary angiography), if the patient has documented, typical symptoms of coronary artery disease. |
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| Maryland, CareFirst Blue Cross Blue Shield |
MD |
Computed tomographic angiography (CTA) for coronary artery disease is considered experimental / investigational as it does not meet TEC criteria #2-5. |
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| Minnesota, Blue Cross and Blue Shield |
MN |
It is the consensus of the Medical Policy Committee that use of computed tomography angiography (CTA) for evaluation of coronary arteries is considered ACCEPTED MEDICAL PRACTICE for the following indications: As an alternative to invasive angiography, following a stress test that is equivocal or suspected to be inaccurate; Evaluation of suspected congenital anomalies of the coronary circulation; Evaluation of acute chest pain or symptoms consistent with acute cardiac ischemia; and Assessment of coronary or pulmonary venous anatomy. All other applications of computed tomography angiography (CTA) of the coronary arteries are considered INVESTIGATIVE, including, but not limited to: Screening for coronary artery disease (i.e., absence of signs or symptoms of disease). Coverage of computed tomography angiography (CTA) for coronary artery assessment is limited to devices that process thin, high-resolution slices (1 mm or less). The multislice scanner must have at least 64 slices per rotation capability. |
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| Montana, Blue Cross and Blue Shield |
MT |
Blue Cross and Blue Shield of Montana (BCBSMT) considers contrast-enhanced computed tomographic angiography for coronary artery evaluation investigational. |
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| Nebraska, Blue Cross and Blue Shield |
NE |
Computed tomographic angiography for coronary artery evaluation is investigative. |
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| New Mexico, Blue Cross and Blue Shield |
NM |
Spiral (Helical) Computed Tomography (Spiral CT, Helical CT) with or without contrast media, when imaging the heart, is considered experimental, investigational, or unproven as: a detection of the risk of obstruction in coronary or cerebral arteries (including calcification) as a screening examination for asymptomatic patients, and a replacement of traditional tests (i.e., stress test[s], coronary angiography), if the patient has documented, typical symptoms of coronary artery disease. |
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| New York, Excellus BlueCross and BlueShield |
NY |
Based on our criteria and review of the peer reviewed scientific literature the use of electron beam computed tomography (EBCT), or the use of spiral CT or multidetector-row computed tomography (MDCT), in imaging the heart of asymptomatic individuals at either a normal or a high risk for coronary artery disease, as yet, has not demonstrated a benefit to patient outcomes by improving prognostic information and is therefore considered not medically necessary. Based on our criteria and review of the peer reviewed scientific literature evidence is inadequate to determine whether EBCT, spiral CT or MDCT is as effective as other commonly used diagnostic tests in selecting symptomatic patients for angiography, and is therefore considered not medically necessary |
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| Pennsylvania, Highmark Blue Shield |
PA |
Computed tomographic angiography (CTA) for the evaluation of coronary arteries is considered eligible for the assessment of suspected congenital anomalies of coronary circulation. CTA of the coronary arteries for all other clinical indications and applications is considered investigational. |
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| South Carolina, Blue Cross and Blue Shield |
SC |
The use of electron beam computed tomography (EBCT), helical CT or multislice spiral (also known as multi-row detector) CT (MSCT) is considered INVESTIGATIONAL/EXPERIMENTAL for the detection of coronary artery calcium, including, but not limited to the following: As part of a cardiac risk assessment in asymptomatic patients. As a diagnostic test in patients considered at intermediate risk for coronary artery disease, where other cardiac tests have been inconclusive. As a diagnostic test in symptomatic patients. Multislice spiral (multi-row detector) computed tomography angiography (CT) as an adjunct to other testing may be MEDICALLY NECESSARY for any of the following: Head and neck vascular imaging (e.g., suspected stroke, subarachnoid hemorrhage, cerebral aneurysms). Detection of a pulmonary embolism. Abdominal vascular imaging (e.g., abdominal aorta, kidneys, mesenteric vasculature and visceral organ). Suspected peripheral arterial disease. Suspected congenital anomalies of the great vessels (e.g., pulmonary artery, aorta). |
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| South Dakota |
SD |
Contrast-enhanced computed tomographic angiography (CTA) is considered investigational for the evaluation of coronary arteries, including, but not limited to the following indications: Screening for coronary artery disease (CAD), either in asymptomatic patients or as part of a preoperative evaluation; Diagnosis of CAD, in patients with acute or non-acute symptoms, or after a coronary intervention; Delineation of a coronary artery anatomy of anomaly. Contrast-enhanced computed tomography angiography is considered investigational as a technique to evaluate cardiac function. |
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| Tennessee, Blue Cross and Blue Shield |
TN |
Electron beam computed tomography for the detection of coronary artery calcification is considered investigational. Multislice spiral computed tomography (i.e. multidetector row computed tomography) for the detection of coronary artery calcification is considered investigational. |
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| Texas, Blue Cross and Blue Shield |
TX |
Spiral (Helical) Computed Tomography (Spiral CT, Helical CT) with or without contrast media, when imaging the heart, is considered experimental, investigational, or unproven as: a detection of the risk of obstruction in coronary or cerebral arteries (including calcification) as a screening examination for asymptomatic patients, and a replacement of traditional tests (i.e., stress test[s], coronary angiography), if the patient has documented, typical symptoms of coronary artery disease. |
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