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. 1. Detection of Symptomatic CAD:

      1. Non acute symptoms with non-high pre-test probability of CAD, uninterpretable ECG OR unable to exercise
      2. Acute symptoms with non-high pre-test probability of CAD, no ECG changes, negative or equivocal biomarkers
      3. Uninterpretable or equivocal stress test

   2. Structure and Function:

      1. Evaluation of suspected coronary anomalies, complex congenital heart disease
      2. Suspected arrhythmogenic right ventricular dysplasia
      3. Evaluation for CAD in new onset or worsening CHF to assess etiology
      4. Detection of CAD prior to non-coronary cardiac surgery
      5. Characterization of dysfunctional native or prosthetic cardiac valves for pre structural interventional evaluation or when inadequately imaged by other noninvasive methods
      6. Evaluation of cardiac mass (tumor versus thrombus) or pericardium
      7. Pre-electrophysiology evaluation of pulmonary veins or coronary veins (pre RFA or BIV)
      8. Non-invasive coronary mapping (including IMA) prior to repeat CABG

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, 5/21, 10/23, 9/24

Revised: 2/08, 1/16, 3/18, 9/22