C9793, 3d predictive model generation for pre-planning of a cardiac procedure, using
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- Medical necessity documentation must meet the requirements of the applicable NCD and/or LCD for the service and the MAC jurisdiction (Humana will apply the referenced LCD criteria; where no LCD exists in jurisdiction, Humana applies the specified LCD used as the surrogate in this policy).
- For FFR_CT, documentation that the CCTA dataset is of adequate quality to permit valid FFR_CT analysis (policy notes: 'The accuracy of FFR_CT depends on the quality of the CCTA study').
- Documentation of clinical indication(s) such as signs/symptoms (e.g., chest pain/pressure/discomfort), known or suspected CAD, congenital coronary anomalies, thoracic aortic disease, valvular heart disease, or other clinical scenarios cited in the applicable LCD supporting use of CCTA/FFR_CT/CACS.
- Interpretation and report by a physician or other qualified health care professional for CPT 75580 (per CPT descriptor: 'with interpretation and report by a physician or other qualified health care professional').
Key Coverage Criteria
- Coronary computed tomography angiography (CCTA) as a noninvasive alternative to invasive cardiac angiography (cardiac catheterization) for diagnosing coronary artery disease (CAD) by visualizing blood flow in the coronary arteries.
- CCTA for assessment of chest pain/pressure/discomfort.
- CCTA for assessment of congenital coronary anomalies.
- CCTA for assessment of thoracic aortic disease.
- CCTA for assessment of valvular heart disease.
- Fractional flow reserve derived from computed tomography (FFR_CT) to evaluate the adequacy of blood flow through the coronary arteries in individuals with known or suspected coronary artery disease (CAD) as a noninvasive alternative to invasive FFR measurement with a pressure catheter.
7 Active Policies
HUMANA-CORONARY-CT-ANGIOGRAPHY-FRACTIONAL-FLOW-RESERVE-WITH-CT-AND-ADJUNCTIVE-TESTING-MA, Coronary CT Angiography, Fractional Flow Reserve with CT and Adjunctive Testing
BCBSIL-SUR707.028, Transcatheter Aortic-Valve Implantation for Aortic Stenosis
BCBSMT-SUR707.028, Transcatheter Aortic-Valve Implantation for Aortic Stenosis
BCBSNM-SUR707.028, Transcatheter Aortic-Valve Implantation for Aortic Stenosis
Related Codes
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