MedicaidCoverageMedium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)
Humana·OK · Cardiology, Internal Medicine·Medicaid
Effective date
Jul 29, 2026
We identified it
Aug 4, 2026
Summary
Humana Medicaid Oklahoma has established a NEW coverage policy for Fractional Flow Reserve with Computed Tomography (FFRCT), effective 07/29/2026. This is a brand new policy (not a revision) that defines specific medical necessity criteria for CPT 75580, including required CCTA-confirmed stenosis ranges (40-90%), risk stratification, and explicit exclusion criteria. Billing teams must implement prior authorization requirements and ensure provider documentation meets the defined clinical criteria.
Action Required
Before 07/29/2026: (1) Billing team must update authorization system to require prior authorization for CPT 75580 with documented medical necessity checklist. (2) Implement automated validation requiring: CCTA-confirmed stenosis 40-90% in proximal/middle coronary artery, intermediate CAD risk >15% (or stable nonobstructive CAD with symptoms despite medical therapy), and documented chest pain characteristics per ACC guidelines. (3) Build system edits to deny claims when patient has exclusion criteria (prosthetic valves, prior CABG, recent MI ≤30 days, pacemaker/defibrillator, stenosis >90%, etc.). (4) Update provider encounter templates to capture required documentation elements: symptom type/duration (acute vs. stable), risk calculator results, prior testing, and medication therapy status. (5) Train authorizers on the three eligible indications and mandatory exclusion criteria. Claims submitted without proper prior authorization or failing medical necessity criteria will be denied. Note: Policy explicitly states evidence is insufficient for this service as standard medical treatment—expect increased denials if clinical criteria not strictly met.