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..

Policy
INDICATIONS FOR CORONARY ARTERY CALCIUM (CAC) TESTING^1-10

See Legislative Requirements for specific mandates in: State of New Mexico and State of Texas

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).

• Patients regardless of age can be considered for CAC testing when there is well-documented evidence of one of the following:
  • Patients with estimated 10-year risk of less than 5%, but are suspected to be at elevated atherosclerotic cardiovascular disease (ASCVD) risk  because of a major risk factor not accounted for in the global risk equations below and consider CAC score as an adjudicator to upgrade risk:^{4, 5, 11, 12}
    • Family history of premature ASCVD
    • Persistently elevated LDL-C > 160mg/dl or non-HDL-C > 190mg/dl
    • Chronic kidney disease
    • Metabolic syndrome
    • Conditions specific to women (e.g., pre-eclampsia, premature menopause)
    • Inflammatory diseases (HIV, psoriasis, RA)
    • Ethnicity (e.g., South Asian ancestry)
    • Persistently elevated triglycerides (> 175mg/dl)
    • hsCRP > 2mg/L
    • Lp(a) levels > 50mg/dl
    • apoB > 130mg/dl
    • ABI < 0.9
  • Patients in whom statin therapy is indicated, but have intolerable adverse effects from, or are reluctant to take statin medication, in order to guide the need for alternative lipid-lowering strategies^{2, 8, 13}
• CAC scoring should be performed in asymptomatic patients. It should not be used as a diagnostic test in patients with symptoms suggestive of ischemia.
• Patients with known CAD should not be considered for calcium scoring as the results are unlikely to affect treatment.^{5, 13-15}
• CAC testing may be repeated for risk re-assessment after a minimum of 5 years, if documentation indicates it will alter management.^{4, 5, 13} It should not be repeated if the patient already has two CAC scores of zero 5 years apart or has a score ≥ 4004.

Rationale
Coronary artery calcium (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.

CAC testing, by either EBCT or non-contrast CCT, provides a quantitative assessment of coronary artery calcium content in Agatston units, as an adjunct to the estimation of global risk for coronary or cardiovascular events over the next 10 years.7 A CAC Score > 0 is a highly specific feature of coronary atherosclerosis.

CAC score > 100 can also provide support for aspirin therapy5, 18 and statin therapy.19 Patients who have already manifested cardiovascular disease are already at high global risk and the Global Cardiovascular Risk Calculators are not applicable.

Links to Global Cardiovascular Risk Calculators^{1, 3, 7, 20, 21}

Abbreviations

References

1. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Sep 10 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010
2. Blankstein R, Gupta A, Rana JS, Nasir K. The Implication of Coronary Artery Calcium Testing for Cardiovascular Disease Prevention and Diabetes. Endocrinol Metab (Seoul). Mar 2017;32(1):47-57. doi:10.3803/EnM.2017.32.1.47
3. Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Jul 1 2014;63(25 Pt B):2935-2959. doi:10.1016/j.jacc.2013.11.005
4. Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary Calcium Score and Cardiovascular Risk. J Am Coll Cardiol. Jul 24 2018;72(4):434-447. doi:10.1016/j.jacc.2018.05.027
5. Hecht H, Blaha MJ, Berman DS, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. Mar-Apr 2017;11(2):157-168.  doi:10.1016/j.jcct.2017.02.010
6. Mahabadi AA, Möhlenkamp S, Lehmann N, et al. CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines. JACC Cardiovasc Imaging. Feb 2017;10(2):143-153. doi:10.1016/j.jcmg.2016.03.022
7. McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study). J Am Coll Cardiol. Oct 13 2015;66(15):1643-53. doi:10.1016/j.jacc.2015.08.035
8. Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. Oct 13 2015;66(15):1657-68. doi:10.1016/j.jacc.2015.07.066
9. Pender A, Lloyd-Jones DM, Stone NJ, Greenland P. Refining Statin Prescribing in Lower-Risk Individuals: Informing Risk/Benefit Decisions. J Am Coll Cardiol. Oct 11 2016;68(15):1690-1697. doi:10.1016/j.jacc.2016.07.753
10. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by  representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. Aug 1 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
11. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 06 18 2019;139(25):e1046-e1081. doi:10.1161/CIR.0000000000000624
12. Golub IS, Termeie OG, Kristo S, et al. Major Global Coronary Artery Calcium Guidelines. JACC Cardiovasc Imaging. Jan 2023;16(1):98-117. doi:10.1016/j.jcmg.2022.06.018 
13. Michos ED, Blaha MJ, Blumenthal RS. Use of the Coronary Artery Calcium Score in Discussion of Initiation of Statin Therapy in Primary Prevention. Mayo Clin Proc. Dec 2017;92(12):1831-1841. doi:10.1016/j.mayocp.2017.10.001
14. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Jul 1 2014;63(25 Pt B):2889-934. doi:10.1016/j.jacc.2013.11.002
15. Wilkins JT, Lloyd-Jones DM. USPSTF Recommendations for Assessment of Cardiovascular Risk With Nontraditional Risk Factors: Finding the Right Tests for the Right Patients. Jama. Jul 17 2018;320(3):242-244. doi:10.1001/jama.2018.9346 
16. § 59A-23-7.16. Heart artery calcium scan coverage. Legislature of the State of New Mexico. Updated March 9, 2020. Accessed February 1, 2023. https://www.nmlegis.gov/Sessions/20%20Regular/final/HB0126.pdf
17. Insurance code: Title 8. Health insurance and other health coverages. Chapter 1376. Certain tests for early detection of cardiovascular disease. Texas State Legislature. Accessed February 1, 2023. https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1376.htm
18. Miedema MD, Duprez DA, Misialek JR, et al. Use of coronary artery calcium testing to guide aspirin utilization for primary prevention: estimates from the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. May 2014;7(3):453-60. doi:10.1161/circoutcomes.113.000690
19. Mortensen MB, Falk E, Li D, et al. Statin Trials, Cardiovascular Events, and Coronary Artery Calcification: Implications for a Trial-Based Approach to Statin Therapy in MESA. JACC Cardiovasc Imaging. Feb 2018;11(2 Pt 1):221-230. doi:10.1016/j.jcmg.2017.01.029
20. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. Jama. Feb 14 2007;297(6):611-9. doi:10.1001/jama.297.6.611
21. D'Agostino RB, Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. Feb 12 2008;117(6):743-53. doi:10.1161/circulationaha.107.699579

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, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated 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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