Is a noninvasive fractional flow reserve calculation after coronary CT angiography (FFR-CT) approved for a patient with a history of supraventricular tachycardia (SVT), hypertension (HTN), and breast cancer, when ordered by a provider who is not a board-certified/board-eligible cardiologist?

FFR-CT Authorization Decision

This request should be DENIED based on the institutional policy requirement that FFR-CT must be ordered by a board-certified/board-eligible cardiologist or radiologist, which has not been met in this case.

Policy Analysis

The institutional policy explicitly requires ALL of the following criteria to be met, and criterion (b) is not satisfied:

• Criterion (b) violation: The test must be "ordered by a BC/BE cardiologist or an advanced practice professional (nurse practitioner or physician assistant) working in collaboration with a BC/BE cardiologist/radiologist" 1
• The FFR-CT was ordered by a provider who is NOT a cardiologist, despite the patient having been evaluated by cardiology for ablation follow-up
• The policy uses "AND" between all criteria, making each one mandatory for approval

Clinical Context Considerations

While the clinical evidence supports FFR-CT utility in appropriate patients, this case presents several concerns beyond the policy violation:

Questionable Clinical Indication

• No documented coronary artery disease: The patient's presentation involves SVT (successfully ablated), hypertension, and anxiety—none of which constitute typical indications for FFR-CT 2, 3
• Normal cardiac function: Echocardiogram shows normal LV systolic function (EF 60%), normal chamber sizes, and normal diastolic filling
• No ischemic symptoms documented: The clinical notes describe palpitations related to AVNRT (now treated), but no chest pain, anginal equivalents, or documented ischemia 1

FFR-CT Evidence Base Limitations

• FFR-CT is validated primarily for patients with known or suspected stable coronary artery disease with intermediate stenoses (30-90%) on coronary CTA 1, 4, 5
• The European Society of Cardiology guidelines note that "non-invasive FFR requires further validation before its clinical use may be justified" 1
• FFR-CT has a rejection rate of 2.9-8.4% due to technical factors, with motion artifacts being the primary cause 6

Missing Clinical Prerequisites

The policy requires that "coronary CT angiography reveals coronary artery disease of uncertain functional significance, i.e., stenosis ≥30% but <90%":

• No documentation provided that the coronary CTA (which was approved separately) has been performed or revealed any stenosis 1
• FFR-CT is specifically designed to assess functional significance of anatomically identified lesions, not as a screening tool 4, 5, 7

Recommendation Pathway

For this request to be reconsidered, the following would need to occur:

1. Cardiology re-evaluation: Have the cardiologist who evaluated the patient for ablation follow-up place the FFR-CT order directly 1
2. Coronary CTA results review: Confirm that the coronary CTA demonstrates stenosis ≥30% but <90% requiring functional assessment 1, 4
3. Clinical indication clarification: Document specific symptoms or findings suggesting coronary ischemia beyond the treated arrhythmia 1, 2

Common Pitfalls to Avoid

• Do not approve based solely on "coronary CTA was approved": FFR-CT approval requires meeting distinct criteria, including appropriate ordering provider and documented anatomic findings 3, 4
• Do not conflate cardiac evaluation with coronary evaluation: This patient was seen by cardiology for electrophysiology follow-up, not coronary disease assessment 1
• Recognize scope of practice boundaries: The policy exists to ensure appropriate specialist oversight for advanced cardiac imaging interpretation 1