Does I25.758 require prior authorization?

No, I25.758 does not require prior authorization (high confidence). Covered without prior authorization.

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`I25.758`, Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All CCTA studies must be ordered by the treating physician or qualified non-physician practitioner who will use the results in patient management and must be performed under the direct supervision of a physician.
Clinical documentation must justify the indication, include presenting signs/symptoms, pre-test probability, and prior relevant test results (e.g., stress testing, myocardial perfusion imaging, cardiac ultrasound, prior invasive angiography) demonstrating that CCTA will provide new information to guide management.
Technical personnel performing image acquisition must be credentialed (e.g., ARRT or equivalent) and meet applicable state licensure requirements.

Key Coverage Criteria

CCTA may be used to reliably rule out significant coronary artery disease (CAD) in patients with low to intermediate pre-test probability of CAD as an alternative to an imaging stress test.
CCTA may be used in a patient presenting with chest pain syndrome when the clinician has a high degree of suspicion that CAD is high on the differential diagnosis.
CCTA may be used to facilitate management in select patients who have an equivocal stress test or stress imaging result.
CCTA may be used to evaluate new or recurrent symptoms in patients with known CAD to assess for progression or exacerbation of underlying coronary disease.
CCTA may be used in patients with prior coronary artery bypass graft (CABG) who present with chest pain or dyspnea to determine graft patency and severity of graft stenoses.
CCTA may be used in patients with prior intracoronary stents who present with recurrent chest pain to evaluate for in-stent restenosis, noting that assessment can be limited by stent-related artifact and scan quality.

20 Active Policies

CGS-J15-L33959, Cardiac Catheterization and Coronary Angiography

J15

CGS-J15-L33960, Cardiovascular Nuclear Medicine

J15

CGS-J15-L40243, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J15

CGS-J15-L33947, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J18-L40244, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J18

CGS-J18-L33960, Cardiovascular Nuclear Medicine

J18

CGS-J18-L33959, Cardiac Catheterization and Coronary Angiography

J18

CGS-J18-L33947, Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA)

J18

CGS-J18-L40243, Temporary Nontherapeutic Ambulatory Cardiac Monitoring Devices

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

WPS-J5-L35121, Coronary Computed Tomography Angiography (CCTA)

WPS-J5-L35490, Category III Codes

WPS-J5-L34761, Percutaneous Coronary Interventions

WPS-J5-L35761, Non-Invasive Peripheral Arterial Vascular Studies

WPS-J5-L34636, Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)

WPS-J5-L39913, Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)

`I25.758`, Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

I25.758, Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`I25.758`, Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris