Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA) - (Effective Date - 2026-10-15) 6.01.34

By October 15, 2026: Billing team and clinical staff must implement the following: (1) Update prior authorization system to require documentation of medical necessity based on the 18 covered indications listed in policy section I (A-R), including specific clinical findings, prior test results, risk factors, or clinical history. (2) Create a clinical decision support checklist in the EMR or billing portal mapping each CCTA request to one of the covered indications (e.g., new/recurrent chest pain, post-stress test evaluation, CAC score >100, age ≥50 with 2+ risk factors, post-PCI/CABG evaluation, anomalous coronary artery evaluation, unexplained sudden cardiac arrest, etc.). (3) For FFR-CT requests (policy section II), require prior documentation that CCTA is recent and shows CAD of uncertain physiologic significance; do not approve FFR-CT without this prerequisite. (4) For coronary CTA plaque quantification (policy section III), require ALL three conditions: acute/stable chest pain with no known CAD, CCTA results showing intermediate risk or CAD-RADS 1-3, and negative/inconclusive acute coronary syndrome evaluation. Deny plaque quantification for unstable syndromes, normal CCTA, CAD-RADS 0, high-grade stenosis >70%, CAD-RADS 4-5, or within 30 days of MI (policy section IV). (5) Provider education: Notify all cardiologists and primary care physicians of the specific indications to avoid claim denials. (6) Billing team: Deny any CCTA claim that does not document one of the 18 approved indications or deny FFR-CT without prerequisite CCTA showing uncertain significance CAD. (7) Update claim scrubbing logic to enforce these criteria before submission to Excellus. Without proper documentation and prior authorization aligned to these indications, claims will be denied post-submission, causing revenue cycle delays and patient billing issues.