Is a noninvasive fractional flow reserve calculation after coronary CT angiography (FFR-CT) approved for a 57-year-old female patient with a history of supraventricular tachycardia (SVT), hypertension (HTN), and breast cancer, who was ordered the test by a provider, not a board-certified/board-eligible cardiologist?

FFR-CT Authorization Decision

This request should be DENIED based on failure to meet the policy's ordering provider requirement, despite the clinical appropriateness of the test itself.

Policy Compliance Analysis

The policy explicitly requires that FFR-CT 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" (criterion 1b). 1

Failed Criterion

• The FFR-CT was ordered by a primary care provider, NOT by cardiology, which directly violates the policy requirement
• While the patient was evaluated by cardiovascular medicine for ablation follow-up, the FFR-CT order itself came from the primary care provider
• The policy language is unambiguous: the ordering provider must be a cardiologist or work in collaboration with one 1

Clinical Context (Does Not Override Policy)

Despite the policy failure, it's worth noting the clinical appropriateness considerations:

Potentially Met Criteria

• Age requirement: Patient is 57 years old (≥18) ✓
• Clinical stability: Patient is stable post-ablation with no acute symptoms ✓
• Coronary CTA ordered: The coronary CTA was previously approved ✓

Unknown/Unclear Criteria

• Stenosis severity: No documentation that the coronary CTA revealed stenosis ≥30% but <90%
• Candidate for invasive angiography: Not explicitly documented
• Results will guide invasive procedure: Not clearly stated in the clinical documentation

Evidence Supporting FFR-CT Clinical Utility

While not relevant to this authorization decision, FFR-CT has demonstrated clinical value:

• FFR-CT improves diagnostic accuracy by reducing false-positive rates compared to anatomic assessment alone, with superior performance for detecting hemodynamically significant lesions 2, 3
• FFR-CT safely defers invasive angiography in patients with stable CAD, reducing ICA rates from 80% to 45% in those with obstructive disease while maintaining safety 4
• High reproducibility: FFR-CT demonstrates coefficient of variation of 3.4% with limits of agreement comparable to invasive FFR measurements 5
• Guideline support: FFR-guided management reduces composite endpoints (death, MI, revascularization) from 8.6% to 4.8% (HR 0.55, P<0.001) compared to angiography-alone strategies 1

Recommendation for Resolution

To obtain authorization, the ordering provider should:

• Have cardiology formally order the FFR-CT study
• Ensure the coronary CTA demonstrates stenosis ≥30% but <90%
• Document that the patient is a candidate for invasive angiography and that results will guide management decisions
• Confirm clinical stability and no need for urgent revascularization

The denial is purely administrative/procedural, not based on clinical inappropriateness of the test. 1, 6, 7