GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations. 

Description:  This guideline includes clinical criteria for coronary artery calcium scoring, by either EBCT or non-contrast CCT. CAC testing provides a quantitative assessment of coronary artery calcium content in Agatston units, as an adjunct to the estimation of global riskⱡ for coronary or cardiovascular events over the next 10 years. A CAC Score > 0 is a highly specific feature of coronary atherosclerosis.^1,2

Clinical Reasoning
All criteria are either supported by Appropriate Use Scores or clinical reasoning that represents a standard of care that considers variables to deliver patient-centered care,
supported by current guidelines endorsed by the American College of Cardiology and the American Heart Association. Care should always be determined on a case-by-case basis and reflect the best needs of the patient.

Policy
INDICATIONS FOR CORONARY ARTERY CALCIUM (CAC) TESTING
Patients, regardless of age, can be considered for CAC testing when there is well- documented evidence of one of the following:^3,4,5,6

• For asymptomatic patients, without known coronary disease, at intermediate global risk (7.5% – 19.9%) (AUC 8)
• For asymptomatic patients, without known coronary disease, that are at either borderline global risk (5% – 7.4%) (AUC 7) or estimated 10-year risk of less than 5%, but are suspected to be at elevated ASCVD risk because of one or more major risk factor (listed below) not accounted for in global risk equations:^{1,3,5,7,8,9,10}
  • Family history of premature ASCVD
  • Persistently elevated LDL-C > 160 mg/dl or non-HDL-C > 190 mg/dl
  • Chronic kidney disease
  • Metabolic syndrome
  • Conditions specific to women (e.g., pre-eclampsia, premature menopause)¹⁰
  • Inflammatory diseases (HIV, psoriasis, RA)
  • Ethnicity (e.g., South Asian ancestry)
  • Persistently elevated triglycerides (> 175 mg/dl)
  • hsCRP > 2 mg/L
  • Lp(a) levels > 50 mg/dl
  • apoB > 130 mg/dl
  • ABI < 0.9, 15
• For asymptomatic patients, without known coronary disease, where there is a need for alternative lipid-lowering strategies when statin therapy is contraindicated, due to adverse effects or patient reluctance^8,9
• CAC testing may be repeated indefinitely for re-assessment of the asymptomatic patient without known coronary disease after a minimum of 5 years until the calcium score breaches 400 or up to twice if the calcium score remains zero.

Rationale
General Overview
CAC testing is for cardiovascular risk assessment in individuals aged 40-75 years who have an intermediate (5% – 19.9%) 10-year ASCVD risk based upon the ACC/AHA pooled cohort risk calculator. Documentation is required that the results of the study will affect decision making for preventative actions (i.e., statin therapy). CAC testing is a cardiovascular risk assessment tool, applicable only to the patient without known cardiovascular disease, for the purpose of primary prevention. It is not for the patient with suspected or known cardiovascular disease, coronary or otherwise, who already requires aggressive risk factor modification. This test is not to be utilized for symptomatic patients in active ischemic evaluation.

CAC score > 100 can also provide support for aspirin therapy and statin therapy.^1,14 Calcium scores are used to help determine the use and dosage of statin therapy in patients with various risks of developing clinically symptomatic atherosclerotic disease. Once symptomatic coronary disease has been established or once the patient is considered high risk, the usefulness of calcium scoring falls away as patients should be on high dose therapy and the results of a calcium score would add no further benefit. If a patient is symptomatic, non-invasive or invasive testing should remain first line.

ⱡ Global risk of CAD is defined as the probability of an asymptomatic patient without known CAD developing CAD, including myocardial infarction or CAD death, over a given period of time. Risk categories include:

• Low risk (< 5%)
• Borderline risk (5% – 7.4%)
• Intermediate risk (7.5% – 19.9%)
• High risk (≥ 20%)

Links to Global Cardiovascular Risk Calculators

Acronyms / Abbreviations
ASCAD: Atherosclerotic coronary artery disease ASCVD: Atherosclerotic cardiovascular disease CAC: Coronary artery calcium
CAD: Coronary artery disease
CCT: Cardiac computed tomography
EBCT: Electron beam computed tomography
 

References

13. Washington State Health Care Authority. WSHCA Health Technology Clinical Committee Coverage Decision 20091120A Coronary Artery Calcium Scoring. 2010; https://www.hca.wa.gov/about-hca/programs-and-initiatives/health-technology-assessment/computed- tomographic-angiography-cta.
14. Mortensen M B, Falk E, Li D, Nasir K, Blaha M J et al. Statin Trials, Cardiovascular Events, and Coronary Artery Calcification: Implications for a Trial-Based Approach to Statin Therapy in MESA. JACC Cardiovasc Imaging. 2018; 11: 221-230. 10.1016/j.jcmg.2017.01.029.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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