Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56902 (Billing and Coding: Category III Codes), Billing and Coding A58473 (Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease) carry the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56902: Billing and Coding: Category III Codes (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 0
- 0 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 13
- Full article
- cms.gov record
Procedure codes: 0075T, 0076T, 0184T, 0308T, 0395T, 0525T, 0526T, 0527T, 0528T, 0529T, 0530T, 0531T, 0532T.
A58473: Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (Billing and Coding, effective 2024-01-01)
- Covered ICD-10-CM codes
- 1
- 1 group
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| R93.1 | — |
Procedure codes: 75580.
Coverage indications, limitations and medical necessity
FDA-approved FFRct technology may be considered reasonable and necessary in the management of patients with:
• Intermediate-risk* patients with acute or stable chest pain and with no known history of coronary artery stenosis with finding of 40-90% in proximal or middle coronary artery on CCTA 1 OR
• Intermediate-risk* patients with acute chest pain and known non-obstructive ( 1 OR
• Stable non-obstructive coronary artery disease ( 1
AND
Not in conjunction with stress testing* (unless CCTA was not sufficient quality for FFRCT, and an alternative study is needed)
*Intermediate and high-risk and stress test as defined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain 1
** Persistent symptoms are defined as unacceptable ischemia-related symptoms despite maximally tolerated medical therapy
FFRct is not considered reasonable in the following clinical circumstances:
• Prior placement of prosthetic valves
• Prior placement of grafts in coronary bypass surgery
• Suspicion of acute coronary syndrome (where MI or unstable angina have not been ruled out)
• Intracoronary metallic stent
• Status post-heart transplantation
• Recent MI (30 days or less)
• Prior pacemaker or defibrillator lead placement
• Newly diagnosed systolic heart failure, with no prior left heart catheterization
• Left main coronary artery disease with Intermediated Coronary Stenosis (lumen reduction less than or equal to 40%)
• Non-obstructing stenosis (
This service should be performed in patients with stable coronary symptoms. It should not be performed until after the base study (CCTA) has been completed and interpreted. If higher grade stenoses (i.e., greater than 90%) are present, this study is not medically necessary, as the patient should proceed to catheterization. Similarly, low-grade stenoses (less than 40%) do not require additional confirmatory data. This should be performed as an alternative to stress testing.
Background
The concept of invasive fractional flow reserve as a diagnostic tool was introduced in the early 1990s. The FAME and FAME-II trials supported an FFR-wire guided revascularization strategy as opposed to purely angiographically guided revascularization. 2 The National Cardiovascular Data Registry demonstrated a low diagnostic yield from traditional exercise stress testing when the patient progressed to invasive coronary angiography. Fractional flow reserve is considered the gold standard for assessing the hemodynamic significance of intermediate coronary stenosis by measuring the pressure difference across a coronary artery stenosis. 3 Intracoronary catheter pressure measurements before and after the stenosis are compared, and FFR of 0.80 correlates with a 20% pressure drop after the stenosis. This measurement can help determine if the vessel narrowing is limiting blood flow and access the need for revascularization or stenting. Clinical studies have demonstrated that invasive FFR reduces unnecessary stenting procedures and associated risk. 2,4 The use of invasive FFR is supported by the Society of Cardiac Angiography and Interventions (SCAI) and American College of cardiology (ACC). 4,5
Noninvasive fractional flow reserve is an alternative modality to gain this information without the need for invasive intracoronary instrumentation in patients with known or suspected coronary artery disease (CAD). FFRct is a fractional flow reserve derived from computed tomography that relies on computer-assisted processing of coronary computed tomographic angiography (CCTA) images to estimate coronary blood flow changes related to coronary artery stenoses. Based on physical theories of fluid dynamic modeling, FFRct is a post-processing software for analyzing previously acquired digital imaging from CCTA. Limitations include that the technology is dependent on the image quality of the CCTA, the images must be sent out for post-processing; therefore, real time results are not feasible, and how to apply FFRct results to clinical practice is still in development. Emerging technologies include virtual FFR (vFFR), where the measurements are based on a 3D image of coronary vessels created by the software using x-ray angiographic imaging. Angio-derived FFR the FFR is calculated at the time of coronary angiogram.
Persistent CAD symptoms are unacceptable ischemia-related symptoms that persist despite optimal medical therapy. Optimal medical therapy is defined by the ISCHEMIA trial protocol 6 as unacceptable ischemia-related symptoms despite maximally tolerated medical therapy. This includes at least 2 anti-anginal drugs from different drug classes added to beta-blocker therapy and titrated to maximally tolerated doses before medical therapy is considered to have failed. 6
Summary of evidence (opening)
The analysis of coronary artery disease by non-invasive coronary computed tomographic analysis has been limited by low specificity. The addition of computer derived flow analysis of the CTA data has added the potential for a non-invasive test that yields both anatomic and functional data. This emerging technology aims to reduce the need for invasive cardiac procedures and associated risks.
The DeFACTO study (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography) compared the first iteration of FFRct technology against invasive angiography and FFR in patients with suspected or known CAD but did not achieve the pre-specified target accuracy. 3 Another study, DISCOVER-FLOW, demonstrated an accuracy of 84.6%. 7 A second iteration of the FFRct algorithm was tested against invasive angiography with FFR in 251 patients with suspected CAD in the NXT (Analysis of Coronary Blood Flow Using CT Angiography- Next Steps) trial. This study reported a diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 81%, 86%, 79%, 65%, and 83%, respectively. 8 In this trial, 484 vessels in 254 patients and found that FFRct significantly improved the per patient specificity and PPV (32 to 84% and 40 to 65%, respectively) and the per vessel specificity and PPV (60 to 86% and 33 to 67%, respectively) compared with CTA. However, this does not translate into benefit compared to CTA alone for identifying patients whose invasive FFR will warrant intervention, and 35% of the abnormal results were false positives. 9 A sub analysis of the NXT study evaluated 206 participants and reported no cardiac death or myocardial infarctions in participants with normal FFRct at a median follow-up of 4.7 years. The authors concluded that an FRRct value of 0.8 or less is a predictor of long-term outcomes driven by planned and unplanned revascularization and is superior to clinically significant stenosis on coronary CCTA. 10
The PROMISE study demonstrated that patients with an FFRct less than or equal to 0.80 were significantly more likely to have coronary revascularization and to meet the composite endpoint of major adverse cardiac events or revascularization than those with FFRct greater than 0.80. 11 The study also showed that reserving invasive coronary angiography for patients with FFRct less than or equal to 0.80 could reduce the rate of performing invasive coronary angiography by 28%. The initial trial did include a CCTA strategy, which did not improve outcomes after 2 years of follow-up. The study, a retrospective, observational, cohort study, also highlighted the dependence of FFRct on the quality of the CCTA images being post-processed, with one-third of the images submitted for review of insufficient quality. 11
The FFRct RIPCORD study involved 200 patients and compared the management of patients by cardiologists, with and without the addition of FFRct data to the baseline CTA data. The additional FFRct data changed the management planform 72 patients (36%) based on lesion severity assessment. With the inclusion of changes in the PCI target vessel, patient management was altered in 44% of patients. 12
The contractor cites 46 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2021-04-25
- Current revision effective
- 2026-05-28
- Last reviewed by the contractor
- 2026-05-05
- MCD version
- 12
Other related documents: A59161 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L38839 cover?
• Intermediate-risk* patients with acute or stable chest pain and with no known history of coronary artery stenosis with finding of 40-90% in proximal or middle coronary artery on CCTA 1 OR The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L38839 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L38839?
The companion billing and coding article A58473 lists 1 ICD-10-CM codes in 1 group that support medical necessity and 1 that do not; the first 1 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L38839?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.