Aetna adds coverage for AI-enabled coronary plaque assessments
Aetna now covers AI-powered plaque quantification on top of coronary CT angiography (CCTA), joining Humana, Cigna, and UnitedHealthcare. With these policies in place, a majority of insured Americans can access these tools through their benefits.
This move aligns with a clear shift in cardiology: using AI to quantify plaque burden directly from CCTA, giving clinicians earlier, clearer risk signals. The FDA has cleared multiple noninvasive plaque analysis tools, and 2024 brought new Category I CPT codes plus higher Medicare payments for CCTA, accelerating adoption.
What Aetna agreed to cover
- Any FDA-cleared plaque quantification software used with a current CCTA exam.
- Patients presenting with acute or stable chest pain.
- No known coronary artery disease (CAD) on record.
- CCTA indicates at least an intermediate risk of CAD.
Coverage is vendor-agnostic as long as the solution is FDA-cleared and used in the clinical context above.
Why this matters for payers
- Market parity: Four major national plans plus Medicare are aligned on coverage, reducing provider friction and appeals.
- Care shift: Expect more CCTA-first strategies and fewer nondiagnostic stress tests for chest pain pathways.
- Downstream efficiency: Better plaque quantification may cut low-yield invasive angiography and enable earlier, targeted therapy.
- Value levers: Clearer risk stratification supports quality metrics and value-based contracts.
Coding, billing, and claims guardrails
These services received Category I CPT codes in 2024, and Medicare increased hospital payment for CCTA, improving financial viability. Build edits that confirm:
- Same-date or recent CCTA exists and is billed appropriately.
- Indication aligns with chest pain and intermediate CAD risk; no known CAD.
- Software documented as FDA-cleared; report includes quantified plaque results.
- Billing is not duplicated across multiple AI analyses for the same study.
Decide whether to require prior authorization for plaque analysis separately from CCTA, or to tie UM to the combined episode. Keep policy language vendor-neutral to avoid lock-in.
Utilization management checklist
- Clinical criteria: chest pain, no known CAD, intermediate risk on CCTA.
- Documentation: link AI report to the source CCTA and clinical decision-making.
- Provider standards: accredited imaging sites; radiation dose and image quality documented.
- Privacy/security: confirm HIPAA-compliant processing, especially for cloud workflows.
- Avoid duplication: deny repeat plaque analyses on the same CCTA unless clinical status changes.
Actuarial and medical economics: what to model
- Unit cost: CCTA plus AI analysis vs. current diagnostic mix.
- Adoption curve: volume growth in ED chest pain and outpatient cardiology.
- Offset savings: reduction in low-yield invasive angiography, fewer repeat testing cycles, medication optimization.
- Quality markers to track: initiation/intensification of preventive therapy, ED returns, invasive angiography positivity rate, MACE rates over 6-12 months.
Vendor landscape and regulatory backdrop
The FDA has cleared plaque analysis solutions from Heartflow, Cleerly, Elucid, Circle Cardiovascular Imaging, Caristo Diagnostics, and Artrya, with more in the pipeline. For a broader view of AI-enabled device clearances, see the FDA's reference page here.
Medicare payment updates have improved the economics for providers. See CMS's 2024 outpatient payment fact sheet here.
What industry leaders are saying
"Aetna's decision to cover Heartflow Plaque Analysis nationwide is a pivotal step in expanding access to our AI-driven plaque quantification and characterization technology," said John Farquhar, president and CEO of Heartflow. "With four major commercial payers and Medicare now recognizing the innovation and value of our platform, more clinicians can gain earlier, clearer insights into coronary plaque."
James K. Min, MD, founder and CEO of Cleerly, added: "Major insurers, covering over 86 million lives, now recognize that AI-QCT delivers better patient outcomes while reducing costs. This is a fundamental shift in how we approach cardiac care."
Action items for payer teams
- Publish or update your medical policy for AI-based plaque quantification, matching the clinical criteria above.
- Align prior authorization and claims edits to the presence of a current CCTA and intermediate risk documentation.
- Educate provider networks on documentation requirements and acceptable FDA-cleared solutions.
- Stand up monitoring: utilization, denial rates, resubmissions, downstream invasive angiography yield, and near-term clinical outcomes.
- Review contracting to ensure fair reimbursement and clarity on bundling vs. separate line items.
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