Cardiac Computed Tomography (CT), Coronary CT Angiography, Calcium Scoring and CT Fractional Flow Reserve (CPB 0228, reviewed 2026-07-21)

By 2026-07-21, the billing and clinical teams must: (1) Update billing system and authorization workflows to enforce the contraindication restrictions—specifically requiring prior authorization denials for CCTA when BMI >40 (unless 3rd generation Dual-Source CT 120-kv tube voltage is utilized), when heart rate cannot be controlled below 80 bpm despite beta blockers, or when uncontrolled atrial fibrillation exists; (2) Implement system edits to flag and deny claims for cardiac CT angiography using less than 64-slice scanners; (3) For plaque quantification/analysis (Cleerly, HeartFlow AI-QCPA, etc.), add requirement in authorization system that only FDA-cleared platforms are billable and only for intermediate risk CAD-RADS 1, 2, 3 (not 4, 5, N) with negative/inconclusive acute coronary syndrome workup; (4) Configure system to deny Nanox.AI HealthCCSng and similar non-diagnostic AI triage software as not medically necessary; (5) Educate providers and clinical staff on the updated criteria, particularly restrictions on asymptomatic screening and the specific pre-test probability risk scoring methods required (Framingham, Pooled Cohort Equations, ACC criteria); (6) Update prior authorization forms and decision trees to reflect these new limitations. Failure to implement these restrictions will result in claim denials and potential fraud/abuse concerns if non-compliant claims are submitted.