Clinical UM Guideline



Subject: Coronary Angiography in the Outpatient Setting
Guideline #:  CG-SURG-44 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description

This document addresses the diagnostic indications for outpatient coronary angiography, that is for elective, non-emergent angiography.  Coronary angiography is an invasive diagnostic evaluation of the heart performed to assess suspected coronary artery disease (CAD).  A coronary angiogram may also be accompanied by a therapeutic percutaneous coronary intervention (PCI), most commonly coronary angioplasty with or without stenting, following angiography.

For information about a related document, see:

Clinical Indications

Medically Necessary:

Coronary angiography is considered medically necessary as part of a coronary evaluation for ANY of the following indications (A-N): 

  1. In individuals with unstable angina, as defined by angina at rest or crescendo angina, and when ANY of following are present (1, 2, or 3):
    1. Acute severe heart failure (HF) that develops after initial presentation; or
    2. Intermediate- or high-risk findings on prior noninvasive ischemia testing (for example, stress testing); or
    3. Thrombolysis in myocardial infarction (TIMI) score equal to or greater than 5; or
  2. In symptomatic individuals at high risk for coronary artery disease (CAD) and no prior noninvasive stress testing who develop signs and symptoms of heart failure (HF); or
  3. In symptomatic individuals with high risk findings on prior noninvasive testing (see Tables 2 and 3) and who are considered to be a candidate for revascularization who meet EITHER of the following criteria (1 or 2):
    1. Decompensating HF with impaired left ventricular (LV) function; or
    2. Persistent anginal symptoms despite a trial of lifestyle modification and guideline-directed medical therapy (GDMT); or
  4. In individuals with suspected CAD based on results of prior noninvasive stress testing who meet ANY of the following (1, 2, or 3):
    1. High risk finding on treadmill stress test, stress myocardial perfusion imaging, stress PET, or stress echocardiography (See Table 2 and 3); or
    2. Resting LV systolic dysfunction (left ventricular ejection fraction [LVEF] less than or equal to 40%) and evidence of myocardial viability in the dysfunctional segment but without clinical evidence of HF; or
    3. Sustained ventricular tachycardia (VT) on stress testing if an ischemic trigger from flow limiting CAD is suspected; or
  5. In individuals with known obstructive CAD (based on prior myocardial infarction [MI], percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG] or stenosis greater than 50% on invasive angiography) with ANY of the following (1, 2, or 3):
    1. New or worsening symptoms with either intermediate or high risk findings on exercise EKG (See Table 2); or
    2. Intermediate or high risk findings on noninvasive stress imaging (See Table 3); or
    3. No symptoms or stable symptoms, but with high risk findings on exercise EKG or stress imaging tests; or
  6. In heart transplant recipients when EITHER of the following situations is present (1 or 2):
    1. No more frequently than every 6 months, angiography to assess for post-heart transplant coronary artery vasculopathy or transplant rejection; or
    2. At 6 months following a PCI to assess for recurrent CAD; or
  7. In individuals with a history of ventricular arrhythmias who meet EITHER of the following criteria (1 or 2):
    1. History of resuscitation from cardiac arrest; or
    2. Ventricular fibrillation or sustained ventricular tachycardia; or
  8. In individuals with symptoms thought to be secondary to CAD with prior testing positive for flow limiting CAD whose symptoms persist despite GDMT; or
  9. In individuals with symptoms thought secondary to CAD with uninterpretable, indeterminate or discordant prior testing for flow limiting CAD whose symptoms persist despite GDMT; or
  10. In individuals with known obstructive CAD, a prior evaluation showing left ventricular segmental dysfunction, and a new wall motion abnormality; or  
  11. In individuals who meet ONE of the following criteria (1, 2, or 3):
    1. Have survived sudden cardiac death, ventricular fibrillation, torsade de pointe or sustained ventricular tachycardia; or
    2. Are being evaluated for kidney, liver or other solid organ transplantation; or
    3. With a new diagnosis of HF with a reduced LVEF less than 50%; or
  12. In individuals with history of CABG or PCI in prior 6 months for left main disease or proximal LAD (left anterior descending), circumflex or RCA (right coronary artery) AND with recurrent angina; or
  13. For the evaluation of suspected anomalous coronary arteries; or
  14. For preoperative assessment before valvular surgery.

Not Medically Necessary:

Coronary angiography is considered not medically necessary when the criteria are not met and for all other applications.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT  
93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;
93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography
93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization
93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
   
ICD-10 Diagnosis  
  All diagnoses
   
Discussion/General Information

The medically necessary criteria within this document are based on a review of the following evidence-based guidelines and other specialty society guidance documents: 

The following tables assist in the assessment of the medical necessity for angiography:

Table 1:* Pre-Test Probability of Coronary Artery Disease by Age, Gender and Symptoms:

Age (yr) Gender Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Non-Anginal Chest Pain Asymptomatic
30-39 Men Intermediate Intermediate Low Very Low
  Women Intermediate Very Low Very Low Very Low
40-49 Men High Intermediate Intermediate Low
  Women Intermediate Low Very Low Very Low
50-59 Men High Intermediate Intermediate Low
  Women Intermediate Intermediate Low Very Low
60-69 Men High Intermediate Intermediate Low
  Women High Intermediate Intermediate Low

*Excerpted from the ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS Appropriate Use Criteria for Diagnostic Catheterization (Patel, 2012).

Table 2:** Classification of EKG Treadmill test results (performed without imaging):

Low risk EKG test result Duke treadmill score > or = +5
Intermediate EKG risk treadmill test result Duke treadmill score -10 to +4
High risk EKG treadmill test result Duke treadmill score < = -11; OR
ST segment elevation; OR
Hypotension with exercise; OR
Ventricular tachycardia; OR
Prolonged ST segment depression

**Excerpted from the ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS Appropriate Use Criteria for Diagnostic Catheterization (Patel, 2012).

Table 3:*** Classification of results of stress tests performed with imaging:

  SPECT MPI+ or Stress PET Stress Echo
Low risk <5% ischemic myocardium No stress induced WMA++
Intermediate risk 5-10% ischemic myocardium Stress induced WMA in a single segment
High risk >10% ischemic myocardium Stress-induced WMA in > or =2 segment; OR
Transient ischemic LV dilation; OR
Significant induced LV dysfunction.

+MPI = myocardial perfusion imaging; ++WMA = wall motion abnormality
***Excerpted from American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Coronary Angiography (Scanlon, 1999).

Definitions

Acute coronary syndrome (ACS): This term primarily refers to ST elevation myocardial infarction (30%), non ST-elevation myocardial infarction (25%), or unstable angina (38%), attributed to obstruction of the coronary arteries, with chest pain being the most common symptom.

Angina pectoris: This term refers to chest pain or discomfort that is typically characterized by the presence of ALL three of the following:

  1. Centrally located or substernal; and
  2. Provoked by exertion or emotional stress; and
  3. Relieved by rest or nitroglycerin.  Chest pain with all three characteristics is considered Definite or typical angina.

Unstable angina: Angina that occurs at rest and is often referred to as crescendo angina, which is characterized by worsening or changing angina and is usually not relieved by nitroglycerin.

Grading of Angina Pectoris by the Canadian Cardiovascular Society Classification System:

Class I: Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina (occurs) with strenuous, rapid, or prolonged exertion at work or recreation.
Class II: Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Angina occurs on walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
Class III: Marked limitations of ordinary physical activity. Angina occurs on walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace.
Class IV: Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.

Cardiac catheterization: A general term describing the use of a thin catheter that is advanced into the bloodstream through an artery at the groin, arm or neck, followed by injection of a contrast agent (dye) that visualizes the coronary arteries and chambers of the heart. Cardiac catheterization, which can be done for diagnostic or therapeutic/interventional purposes or both, can be used to describe imaging of the coronary arteries, (also referred to as coronary angiography), or the heart chambers.

Chest pain (non-anginal): Chest pain or discomfort that meets one or none of the typical angina characteristics.

Congenital heart disease: A general term describing abnormalities in the structure of the heart that are present at birth. The abnormalities can include abnormal heart valves or abnormal communications between the different chambers of the heart.

Congestive heart failure (CHF) or heart failure: A condition in which the heart no longer adequately functions as a pump. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the lungs and other organs.

Coronary angiography: A cardiac catheterization procedure (see definition above) that is used to visualize the coronary arteries. 

Coronary angioplasty: A therapeutic catheterization procedure that often follows the initial diagnostic imaging procedure. A small balloon placed at the site of the blockage in the coronary artery is inflated, in order to reopen the artery. Frequently a stent is also placed in the artery to maintain the opening. 

Guideline-directed medical therapy (GDMT): For context within this document, this terminology, which was formerly referred to as "Optimal medical therapy," is defined as the use of at least 2 classes of medication to reduce angina symptoms (for example, beta blockers, calcium channel blockers, nitrate preparations, ranolazine).  In the event that an individual is unable to tolerate 2 anti-angina medications, the maximum tolerated level of medical therapy will be considered to be GDMT.

Imaging procedure: This is a general term describing a technique to provide an image of a structure; in this case, a picture of the heart or coronary arteries. Angiography and right and left heart catheterization produce images by injecting dye into the heart chambers or coronary arteries, respectively. Other types of cardiac imaging procedures include echocardiography, CT or MRI scans.

Left heart: Describes the two chambers on the left side of the heart; the left atrium, which receives oxygenated blood from the lungs, and the left ventricle, which pumps the blood through the circulation.

Left ventricular ejection fraction (LVEF): The measurement of the heart's ability to pump blood through the body.  Normal LVEF readings would be in the 58-70% range.

Myocardial infarction (MI): The medical term for heart attack. A heart attack occurs when the blood supply to part of the heart muscle (the myocardium) is severely reduced or blocked.

New York Heart Association (NYHA) definitions:

The NYHA classification of heart failure is a 4-tier system that categorizes subjects based on subjective impression of the degree of functional compromise; the four NYHA functional classes are as follows:

Percutaneous coronary intervention (PCI): A general term describing a therapeutic procedure that is done at the same time as cardiac catheterization. The most common PCI is a coronary angioplasty with or without stent placement to treat the coronary artery disease identified in the immediately previous coronary angiography.

Pericardial tamponade: An acute condition where pressure builds up around the heart, impairing cardiac function, due to fluid accumulation in the pericardial sac, which is referred to as pericardial effusion.

Pericarditis (restrictive): Refers to inflammation of the pericardial sac, which is termed restrictive or constrictive when the inflammatory process results in diminished ability of the heart to beat normally. This condition is usually due to an infection but it may also occur following an MI or cardiac surgery.                                                                                                 

Pulmonary hypertension: A rare lung condition where increased pressure in the pulmonary artery compromises cardiopulmonary function.

Right heart: Describes the two chambers on the right side of the heart; the right atrium, which receives the blood returning from the rest of the body, and the right ventricle that pumps this blood to the lungs.

Structural heart disease: A general term describing abnormalities in the structure of the heart, which includes diseases of the valves or congenital heart disease (present at birth). A cardiac catheterization procedure can evaluate the structure and function of the heart by assessing the left ventricular ejection fraction (see definition above), as well as the movement of the valves of the heart and of the chamber walls. 

Valvular heart disease (VHD): Valvular heart disease is characterized by damage to, or a defect in, one of the four heart valves: the mitral, aortic, tricuspid or pulmonary.  The severity of symptoms does not necessarily correlate with the severity of VHD which is defined in stages (See Table 4) based on valve anatomy, valve hemodynamics, severity of LV dilation and LV systolic function, as well as by the presence of symptoms.  The symptoms are related to the underlying cause of the VHD, which may be aortic stenosis (blockage), aortic regurgitation (valve leakage), bicuspid aortic valve, mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, and pulmonic regurgitation, but may include:

Vasculopathy: A term that refers to any disorder or disease process affecting the blood vessels.

References

Peer Reviewed Publications:

  1. Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med. 2013; 368(15):1379-1387.
  2. Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009; 360(26):2705-2718.
  3. Di Mario C, Dudek D, Piscione F, et al. Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomized, multicenter trial. Lancet. 2008; 371(9612):559-568.
  4. Nallamothu BK, Spertus JA, Lansky AJ, et al. Comparison of clinical interpretation with visual assessment and quantitative coronary angiography in patients undergoing percutaneous coronary intervention in contemporary practice: the Assessing Angiography (A2) project. Circulation. 2013; 127(17):1793-800.
  5. O'Connor CM, Hasselblad V, Mehta RH, et al. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. J Am Coll Cardiol. 2010; 55(9):872-878.
  6. Tricoci P, Lokhnygina Y, Berdan LG, et al. Time to coronary angiography and outcomes among patients with high-risk non ST-segment elevation acute coronary syndromes: results from the SYNERGY trial. Circulation. 2007; 116(23):2669-2677.
  7. van Nunen LX, Zimmermann FM, Tonino PA, et al.; FAME Study Investigators. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomized controlled trial. Lancet. 2015; 386(10006):1853-1860.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 127(23):e663-e828.
  2. Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions (ACCF/SCAI) expert consensus document on cardiac catheterization laboratory standards update. J Am Coll Cardiol. 2012; 59(24):2221-2305.
  3. Centers for Disease Control (CDC). Million Hearts: Strategies to reduce the prevalence of leading cardiovascular disease risk factors. United States, 2011. MMWR. 2011; 60(36):1248-1251.
  4. Costanzo MR, Dipchand A, Starling R, et al. The International Society of Heart and Lung Transplantation (ISHLT) Guidelines for the care of heart transplant recipients. J Heart/Lung Transpl. 2010; 29(8):914-956.
  5. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012; 60(24):e44-e164.
  6. Greenwood JP, Ripley DP, Berry C, et al. Effect of care guided by cardiovascular magnetic resonance, myocardial perfusion scintigraphy, or NICE guidelines on subsequent unnecessary angiography rates: the CE-MARC 2 randomized clinical trial. JAMA. 2016; 316(10):1051-1060.
  7. National Institutes of Health (NIH). Multiple ongoing trials regarding cardiac catheterization and angioplasty.  Available at: http://clinicaltrials.gov/ct2/results?fund=0&fund=1&recr=Open&term=Cardiac+Catheterization. Accessed on July 3, 2017
  8. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63(22):e57-185.
  9. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 127(4):e362-e425. Available at:  http://circ.ahajournals.org/content/127/4/e362.full.pdf+html. Accessed on July 3, 2017.
  10. Patel MR, Bailey SR, Bonow RO, et al.  ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 2012; 144(1):39-71.
  11. Ripley DP, Brown JM, Everett CC, et al. Rationale and design of the clinical evaluation of magnetic resonance imaging in coronary heart disease 2 trial (CE-MARC 2): a prospective, multicenter, randomized trial of diagnostic strategies in suspected coronary heart disease. Am Heart J. 2015; 169(1):17-24.
  12. Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol.1999; 33(6):1756-1824.
  13. University of Leeds. Clinical evaluation of magnetic resonance imaging in coronary heart disease-2 (CE-MARC2). NCT01664858. Last updated March 27, 2015. Available at: https://clinicaltrials.gov/show/NCT01664858 . Accessed on July 3, 2017.
  14. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation. 2008; 118(23):2395-2451. Available at:  http://circ.ahajournals.org/content/118/23/2395.full.pdf. Accessed on July 3, 2017.
  15. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014; 63(4):380-406.
  16. Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused update of the guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011; 123(18):2022-2060. Available at: http://circ.ahajournals.org/content/123/18/2022.full.pdf. Accessed on July 3, 2017.
  17. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guidelines for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 128(16):e240-e327.
Websites for Additional Information
  1. Go AS, Mozaffarian D, Roger VL, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013; 127(1):e6-e245. Available at:  http://circ.ahajournals.org/content/127/1/e6. Accessed on July 3, 2017.
  2. 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. Circulation. 2014; 129(25 Suppl 2):S49-S73. Available at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98.short?rss=1&ssource=mfr. Accessed on June 30, 2017.
  3. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). Cardiac catheterization. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/cath/. Accessed on June 30, 2017.
  4. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). Coronary Angioplasty. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/angioplasty/. Accessed on June 30, 2017.
Index

Angiogram, Coronary
Angiography, Coronary
Catheterization, Cardiac

Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. The References were updated.
Revised 08/04/2016 MPTAC review. Updated formatting in Clinical Indications section. The Description and References were updated.
Revised 05/05/2016 MPTAC review. The clinical indications section has been revised to remove criteria for right and/or left heart catheterization and for angiography with right and/or left heart catheterization. The Description section was revised to narrow the scope of this document to coronary angiography only. The title was changed to, Coronary Angiography in the Outpatient Setting. Criterion No. (D, 1) was clarified to include treadmill stress testing. Evaluation of suspected anomalous coronary arteries and preoperative assessment before valvular surgery were added to the medically necessary indications for performing coronary angiography (Criterion No. M and N). The Coding section, Discussion section and References were updated.
Revised 02/04/2016 MPTAC review. The medically necessary criteria for coronary angiography have been revised to include, "Post-transplant rejection monitoring" (Section F, 1) and to clarify with the addition of, "Absence of clinical presence of HF" in the setting of suspected CAD with LV dysfunction, LVEF less than or equal to 40%, and segment viability (Section D, 2). The medically necessary criteria for right and/or left heart catheterization, when results of prior noninvasive testing have been equivocal or discordant, were revised to include, "Pre-heart transplant evaluation and post-heart transplant evaluation for rejection with or without biopsy" (Section II, a,b). The Definitions and References were updated. Removed ICD-9 codes from Coding section. 
Revised 08/06/2015 MPTAC review. Small revisions made to the medically necessary criteria for clarification. The Definitions were updated.
Revised 05/07/2015 MPTAC review. The medically necessary indications for coronary angiography have been revised for clarification. References were updated.
Revised 02/05/2015 MPTAC review. Clarified language was added regarding coronary angiography in symptomatic individuals with high risk for CAD and no prior stress testing, also for coronary angiography in individuals with known CAD, and for coronary angiography in heart transplant recipients at 6 months following PCI to assess for recurrent CAD. The Discussion section and References were updated.
Reviewed 10/13/2014 MPTAC review and interim vote to approve.
New 08/14/2014 MPTAC review. Initial guideline development.