Is Preauth Required? According to the information provided, preauthorization is required for CT scans to diagnose chest pain when the patient has known but stable, asymptomatic cardiac or pulmonary disease. The reason for the CT scan must be documented in the clinical chart with an explanation of how the results of the scan will be used for the patient's care.
Will the claim be denied? Based on the provided information, a CT scan may be used in lieu of an imaging stress test for a patient presenting with chest pain and a high degree of suspicion that CAD is on the differential diagnosis of the symptoms. In this case, the claim should not be denied.
When is the following treatment medically necessary for the condition specified? A CT scan of the chest is considered medically necessary for the condition of chest pain when the clinician has a high degree of suspicion that CAD is high on the differential diagnosis of symptoms and when the patient has an equivocal stress test. The CT scan would allow for an alternate method of assessing the coronary arteries, which would limit the number of negative invasive coronary angiograms.
What would make the following treatment considered medically necessary? CT scan is considered medically necessary when the patient is presenting with chest pain and has an intermediate pre-test probability of Coronary Artery Disease (CAD). It is expected to avoid diagnostic cardiac catheterization and can be used to evaluate suspected symptomatic Coronary Artery Disease (CAD).
What are the relevant codes for the treatment? The billing and coding guidance for a CT scan of the chest for chest pain is to use CPT code 71275, Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries, plus one of the following CPT codes: 75571, 75572, 75573, or 75574.
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