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Date Printed: May 21, 2018: 02:32 PM

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04-78000-19

Original Effective Date: 07/01/07

Reviewed: 04/26/18

Revised: 05/15/18

Subject: Cardiac Nuclear Imaging (Myocardial Perfusion Imaging)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

This guideline addresses cardiac stress imaging, specifically myocardial perfusion imaging (MPI) with appropriate alternatives, such as stress echocardiography (stress echo) or stress electrocardiogram (EKG) alone, when appropriate using the following principles:

• A stress EKG alone is often appropriate. A baseline EKG which does not allow interpretation of ischemic findings with exercise will sometimes (but not always); require the addition of stress imaging.

• When stress imaging is appropriate, as an addition to stress EKG alone, stress echo is preferred when the member is able to exercise and MPI is preferred when the member cannot exercise.

• When stress echo is precluded by specific imaging difficulties (e.g. poor quality image despite contrast medium, uncontrolled atrial fibrillation, ventricular paced rhythm, baseline wall motion abnormalities) as noted in the “additional information” section), then MPI is preferable.

Compelling indications (e.g. ACC Class I or IIA or Appropriate Use Criteria ‘A’) for cardiac stress imaging (MPI and echo) are the foundation, and the less compelling indications (IIB or ‘M’) have been selected as appropriate for those clinical scenarios in which the clinical presentation incurs high risk. If a member fits two or more clinical scenarios, the clinical scenario which supports cardiac stress imaging (MPI or echo) supersedes the clinical scenario which does not.

Issues such as pretest probability, global risk of coronary or cardiovascular disease, anginal equivalent, aspects of different types of stress testing are discussed in the “additional Information” section of this guideline.

This guideline is organized around the following seven clinical scenarios:

I. Suspected Coronary Artery Disease (CAD)

II. Incompletely Evaluated Coronary Artery Disease (CAD)

III. Follow-up of Known Ischemic Coronary Artery Disease (CAD)

IV. Coronary Artery Disease (CAD) in the Presence of Other New Cardiac Concerns

V. Prior to Noncardiac Surgery

VI. Prior to Cardiac Rehabilitation or Exercise Program

VII. Post Cardiac Transplantation

POSITION STATEMENT:

Myocardial perfusion imaging (MPI) meets the definition of medical necessity for the following:

I. Suspected Coronary Artery Disease (CAD)

Suspected coronary artery disease (CAD): high global risk asymptomatic, stable symptomatic or low risk unstable symptomatic (Refer to Table 6 and 7)

II. Incompletely Evaluated Coronary Artery Disease (CAD)

Incompletely evaluated CAD: requires further evaluation within 2 years of a prior coronary evaluation for clarification of diagnosis or disease severity

III. Follow-up of Known Ischemic Coronary Artery Disease (CAD)

Routine follow-up when last invasive or non-invasive assessment of coronary artery disease showed hemodynamically significant CAD (ischemia on stress test or FFR <= 0.80 for a major vessel or stenosis >=70% of a major vessel) over two years ago, without supervening coronary revascularization, is an appropriate indication for stress imaging (MPI or echo) in members with high risk clinical scenarios, such as left ventricular dysfunction (ejection fraction less than 50%) or severe un-revascularized multivessel CAD (if it will alter management), or in members with high risk occupations (e.g. associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers, and firefighters) or a high personal risk (e.g. scuba divers).

IV. Coronary Artery Disease (CAD) in the Presence of Other New Cardiac Concerns

V. Prior to Noncardiac Surgery

VI. Prior to Cardiac Rehabilitation or Exercise Program

VII. Post Cardiac Transplantation

Additional Information:

Definitions of Coronary Artery Disease:

Definition of Peripheral Arterial Disease/Cerebrovascular Disease:

Non-coronary arterial narrowing causing symptoms (claudication, related tissue demise, threatened limb loss), asymptomatic 70% or more narrowing by non-invasive or invasive evaluation, atherosclerotic arterial aneurysm by non-invasive or invasive evaluation, or aortic atheroma of at least 4 mm thickness. As a subset of peripheral arterial disease, cerebrovascular disease is also defined as a history of stroke or TIA.

Anginal Equivalent

Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons to suspect that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest (CTA)), and/or pulmonary function tests (PFTs) when appropriate). An angina equivalent is then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope by itself is generally not considered an anginal equivalent, and is handled under a separate category in this guideline.

Pretest Probability for Coronary Artery Disease (CAD):

Pretest probability is a reference to symptoms that need evaluation as potentially coronary in origin.

Typical Angina (Definite): Defined as:

Atypical Angina (Probable): Chest pain or discomfort that lacks 1 of the characteristics of definite or typical angina.

Nonanginal Chest Pain: Chest pain or discomfort that meets 1 or none of the typical angina characteristics.

Note: Angina: As defined by the American College of Cardiology (ACC)/American Heart Association (AHA).

Once the presence of symptoms (typical angina, atypical angina and nonanginal chest pain) is determined, the probabilities of CAD can be calculated from the risk algorithms as follows:

Age (Years)

Gender

Typical/Definite Angina Pectoris

Atypical/Probable Angina Pectoris

Nonanginal Chest Pain

Asymptomatic

30-39

Men

Intermediate

Intermediate

Low

Very low

Women

Intermediate

Very low

Very low

Very low

40 – 49

Men

High

Intermediate

Intermediate

Low

Women

Intermediate

Low

Very low

Very low

50-59

Men

High

Intermediate

Intermediate

Low

Women

Intermediate

Intermediate

Low

Very low

60-69

Men

High

Intermediate

Intermediate

Low

Women

High

Intermediate

Intermediate

Low

Very low: Less than 5% pretest probability of CAD

Low: Less than 10% pretest probability of CAD

Intermediate: Between 10% and 90% pretest probability of CAD

High: Greater than 90% pretest probability of CAD

Global Risk of CAD or Vascular Disease

Global risk of CAD is defined as the probability of developing CAD, including myocardial infarction or CAD death over a given time period and refers to asymptomatic patients without known coronary artery disease. It should be determined by the Framingham Risk Score (ATP IV risk tool), the Reynolds Risk Index, or the Pooled Cohort Equation (which includes cerebrovascular risk). A high risk is considered greater than a 20% risk of a coronary or major vascular event over the ensuing 10 years.

CAD Risk—Low: Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk less than 10%.

CAD Risk—Moderate: Defined by the age-specific risk level that is average or above average. In general, moderate risk will correlate with a 10-year absolute CAD risk between 10% and 20%.

CAD Risk—High: Defined as the presence of peripheral arterial disease, cerebrovascular disease, or a 10-year absolute CAD risk of greater than 20%.

Online cardiac risk calculator and assessment tools:

The links for the online cardiac risk calculator and assessment tools are to an outside source and is provided for your convenience. Use of the links and related calculator and assessment tools are subject to the terms and conditions of the website and is not warranted, maintained or affiliated with Florida Blue.

Framingham Risk Score Calculator

https://www.framinghamheartstudy.org/

http://tools.acc.org/ASCVD-Risk-Estimator/

Reynolds Risk Score

http://www.reynoldsriskscore.org/

Pooled Cohort Risk Assessment Equations

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

Duke Treadmill Score

The equation for calculating the Duke treadmill score (DTS) is, DTS = exercise time in minutes - (5 * ST deviation in mm or 0.1 mV increments) - (4 * exercise angina score), with angina score being 0 = none, 1 = non limiting, and 2 = exercise-limiting. The score typically ranges from -25 to +15. These values correspond to low-risk (with a score of >/= +5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of </= -11) categories.

Determinants of a 4 Metabolic Equivalents (MET) Functional Capacity

Examples of activities:

<4 METs: Slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at approximately 2 mph to 3 mph

>4 METs: Climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house

Characterization of Unstable Angina

Three Principal Presentations of Unstable Angina (as defined within a two week timeframe)

Class

Presentation

Rest angina*

Angina occurring at rest and prolonged, usually > 20 minutes

New-onset angina

New-onset angina of at least CCS Class III severity

Increasing angina

Previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by ≥ 1 CCS class to at least CCS Class III severity)

*Patients with NSTEMI usually present with angina at rest.

Abbreviation: CCS= Candian Cardiovascular Society

Adapted from: Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American Colleg of Cardiology 2007; 50(7): 652-726

Table 6: Likelihood that Symptoms Represent an Acute Coronary Syndrome

Feature

High Likelihood

Any of the following:

Intermediate Likelihood

Absence of high-likelihood features and presence of any of the following:

Low Likelihood

Absence of high-or intermediate- likelihood features but may have:

History

Chest or left arm pain or discomfort as chief symptom reproducing prior

documented angina

Known history of CAD, including MI

Chest or left arm pain or discomfort as chief symptom

Age greater than 70 years

Male sex

Diabetes mellitus

Probable ischemic symptoms in absence

of any of the intermediate likelihood characteristics

Recent cocaine use

Examination

Transient MR, hypotension, diaphoresis, pulmonary edema, or rales

Extracardiac vascular disease

Chest discomfort reproduced by palpation

ECG

New, or presumably new, transient ST segment deviation (1 mm or greater) or T-wave inversion in multiple precordial leads

Fixed Q waves

ST depression 0.5 to 1 mm or T-wave inversion greater than 1mm

T-wave flattening or inversion less than 1mm in leads with dominant R waves

Normal ECG

Cardiac markers

Elevated cardiac TnI, TnT, or CK-MB

Normal

Normal

Abbreviations: ACS= acute coronary syndrome; CAD= coronary artery disease; CK-MB= creatine kinase, MB fraction ; ECG= electrocardiogram; MI= myocardial infraction; MR= mitral regurgitation; TnI= troponin I; TnT= troponin T

Adapted from: Braunwald E, Antman EM, Beasley JW et al. ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction. : a report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina). Journal of the American College of Cardiology 2000; 36(3): 970-1062

Table 7: *Short Term Risk of Death or Nonfatal MI in Acute Coronary Syndrome in Acute Coronary Syndrome

Feature

High Risk

At least 1 of the following features must be present:

Intermediate Risk

No high-risk feature but must have 1 of the following:

Low Risk

No high- or intermediate-risk feature but may have any of the following features:

History

Accelerating tempo of ischemic

symptoms in preceding 48h

Prior MI, peripheral or cerebrovascular

disease, or CABG, prior aspirin use

Increased angina frequency, severity, or duration

Angina provoked at a lower threshold

New onset angina with onset 2 weeks to 2 months prior to presentation

Character of pain

Prolonged ongoing (greater than 20 minutes)

rest pain

Prolonged (greater than 20 min) rest angina, now resolved, with moderate or high likelihood of CAD

Rest angina (greater than 20 min) or relieved with rest or sublingual NTG

Nocturnal angina

New-onset or progressive CCS class III or IV agina in the past 2 weeks without prolonged (greater than 20 min) rest pain but with intermediate or high likelihood of CAD (see Table 6)

 

Clinical findings

Pulmonary edema, most likely due to ischemia

New or worsening MR murmur

S3 or new/worsening rales

Hypotension, bradycardia, tachycardia

Age greater 75 years

Age greater than 70 years

 

ECG

Angina at rest with transient ST-segment

changes than 0.05 mm

Bundle-branch block, new or presumed new

Sustained ventricular tachycardia

T-wave changes

Pathological Q waves or resting than lmm in multiple lead groups (anterior, inferior, lateral)

Normal or unchanged ECG

Cardiac markers

Elevated cardiac TnT, TnI or CK-MB (e.g., TnT or TnI greater than.0.1 ng/ml)

Slightly elevated (e.g., TnT greater than .0.01 but less than 0.1 ng/mL)

Normal

*Estimation of the short-term risks of death and nonfatal cardiac ischemic events in UA (or NSTEMI) is a complex multivariable problem that cannot be fully specified in a table such as this; therefore, this table is ment to offer general guidance and illustration rather than rigid algorithms. Adopted from AHCPR Clinical Practice Guidelinelines No. 10, Unstable Angina: Diagnosis and Management, May 1994 (124).

Abbreviations: CABG= coronary artery bypass graft surgery; CAD= coronary artery disease; CCS= Canadian Cardiovascular Society; CK-MB= creatine kinase, MB fraction; ECG= electrocardiogram; MI= myocardial infraction; MR= mitral regurgitation; NTG= nitroglycerin; TnI= troponin I; TnT= troponin T; UA/NSTEMI= unstable angina/non-ST elevation myocardial infarction

Adapted from: Braunwald E, Jones RH, Mark DB et al. Diagnosing and managing unstable angina. Agency for Health Care Policy and Research. : Circulation 1994; 90(1): 613-622

Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American Colleg of Cardiology 2007; 50(7): 652-726

The TIMI Risk Score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables: age ≥65 years, at least 3 risk factors for CAD, prior coronary stenosis of ≥50%, ST-segment deviation on ECG presentation, at least 2 anginal events in prior 24 hours, use of aspirin in prior 7 days, and elevated serum cardiac biomarkers Low-Risk TIMI Score: TIMI score <2; High-Risk TIMI Score: TIMI score ≥2. A low risk TIMI score might still warrant invasive coronary arteriography, when other features, such as symptoms, are compelling.

Abbreviations:

AAD - Antiarrhythmic drug

ADLs - Activities of daily living

Bpm - Beats per minute

CAD - Coronary artery disease

CCS - Canadian Cardiovascular Society

CCTA - Coronary computed tomographic angiography

CFR - Coronary flow reserve

CKD - Chronic kidney disease

CK-MB - Creatine kinase

DTS - Duke treadmill score

Echo - Echocardiography

EKG - Electrocardiogram

FFR - Fractional flow reserve

IVUS - Intravascular ultrasound

LBBB - Left bundle-branch block

LVH - Left ventricular hypertrophy

MI Myocardial infarction

MESA - Multi-Ethnic Study of Atherosclerosis

MET - Metabolic equivalents (of exercise)

MPI- Myocardial perfusion imaging

NSTEMI - Non-ST segment elevation myocardial infarction

PFT - Pulmonary function test

PVCs - Premature ventricular contractions

TIA - Transient ischemic attack

TIMI - Thromoblysis In Myocardial Infarction

VF - Ventricular fibrillation

VT - Ventricular tachycardia

WPW - Wolf Parkinson White

BILLING/CODING INFORMATION:

CPT Coding:

78451

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

78452

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic and/or redistribution and/or rest reinjection

78453

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

78454

Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and or redistribution and/or rest reinjection

78466

Myocardial imaging, infarct avid, planar; qualitative or quantitative

78468

Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique

78469

Myocardial perfusion imaging; tomographic SPECT with or without quantification

78481

Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

78483

Cardiac blood pool imaging, (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

REIMBURSEMENT INFORMATION:

Re-imaging due to technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for cardiac nuclear imaging (myocardial perfusion imaging).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Cardiology-non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET, (L36209) is located at fcso.com

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) for Cardiac Nuclear Imaging Studies.

DEFINITIONS:

Agatston score: a calcium score; the score is based on the amount of calcium found the coronary arteries.

Ejection fraction (EF): the proportion, fraction or percentage of blood pumped out of the heart with each beat. An EF is 55 percent or higher.

Electrocardiogram (EKG, ECG): a test that records the electrical activity of the heart that is used in diagnosing some heart abnormalities.

Electrogradiogram (ECG)-uninterpretable: ECGs with resting ST-segment depression (less than or equal to 1.10 mV), complete left bundle-branch block (LBBB), pre-excitation Wolff-Parkinson-White syndrome (WPW) or paced rhythm.

ST segment: on an electrocardiogram, the interval from the end of ventricular depolarization to the onset of the T wave.

ST segment elevation myocardial infarction (STEMI): subcategories of acute coronary syndrome (ACS).

Non-ST-segment elevation myocardial infarction (NSTEMI): subcategories of acute coronary syndrome (ACS).

Stress test: A heart monitoring test to discover how well the heart works usually performed via physical exercise, and sometimes via pharmaceuticals.

Wolff-Parkinson-White syndrome: the association of paroxysmal tachycardia or atrial fibrillation with pre-excitations; used synonymously with pre-excitation, also, called WPWs.

RELATED GUIDELINES:

Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02

Multiple-Gated Acquisition (MUGA) Scan, 04-78000-21

OTHER:

None applicable.

REFERENCES:

  1. Anderson JL, Adams CD, Antman EM et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 50(7): 652-726.
  2. Berman DS, Hachamovitch R, Shaw LJ et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: Noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. Journal of Nuclear Medicine 2006; 47(7): 1107-1118.
  3. Braunwald E, Antman EM, Beasley JW et al. ACC/AHA guidelines for the management of patients with unstable angina and non–st-segment elevation myocardial infarction. a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (committee on the management of patients with unstable angina). Journal of the American College of Cardiology 2000; 36(3): 975-1061.
  4. Braunwald E, Jones RH, Mark DB et al. Diagnosing and managing unstable angina. Agency for Health Care Policy and Research. Circulation 1994; 90(1): 613-622.
  5. Bunch TJ, Chandrasekaran K, Gersh BJ et al. The prognostic significance of exercise-induced atrial arrhythmias. Journal of the American College of Cardiology 2004; 43(7): 1236-1240.
  6. Cha YM, Lee GK, Klarich KW et al. Premature ventricular contraction-induced cardiomyopathy a treatable condition. Circulation Arrhythmia and Electrophysiology 2012; 5:229-236.
  7. Douglas PS, Hendel RC, Peterson ED et al. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI), 2005.
  8. Fern′ndez-Lozano I, Brugada J. Right bundle branch block: are we looking in the right direction? European Heart Journal 2013; 34: 86-88.
  9. Fihn SD, Gardin JM, Abrams J et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease.  a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126: e354-e741.
  10. Fleisher LA, Fleischmann KE, Auerbach AD et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2014; 64(22): e77-e137.
  11. Futterman LG, Lemberg L. The clinical significance of experience-induced ventricular arrhythmias. American Journal of Critical Care 2006; 15(4): 431-435.
  12. Gibbons RJ, Balady FJ, Beasley JW et al. ACC/AHA Guidelines for Exercise Testing: Executive Summary. a Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Journal of the American College of Cardiology 2002; 40(8): 1531-1540.
  13. Goff DC, Lloyd-Jones DM, Bennett G et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129 [suppl. 2]: S74-S75.
  14. Goff DC, Lloyd-Jones DM, Bennett G et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2014; 63(25): 2937-2959.
  15. Hansen CL, Goldstein RA, Akinboboye OO et al. ASNC imaging guidelines for nuclear cardiology procedures: myocardial perfusion and function: single photon emission computed tomography 2007; 14: e39-e60.
  16. Hendel RC, Berman DS, Di Carli MF et al. ACCF/ASNC/ARC/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation appropriate use criteria task force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine: endorsed by the American College of Emergency Physicians. Circulation 2009; 119(22): e561-e587.
  17. Jeevanantham V, Manne K, Sengodan M et al. Predictors of coronary artery disease in patients with left bundle branch block who undergo myocardial perfusion imaging. Cardiology Journal 2009; 16(4): 321-326.
  18. Kavousi M, Leening MJG, Nanchen D et al. Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines, and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European Cohort. Journal of American Medical Association 2014; 311(14): 1416-1423.
  19. Klocke FJ, Baird MG, Bateman TM et al. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging-Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC committee to revise the 1995 guidelines for the clinical use of cardiac radionuclide imaging). Circulation 2003; 108; 1404-1418.
  20. Montalescot G, Sechtem U, Achenbach S et al. 2013ESC guidelines on the management of stable coronary artery disease. The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. European Heart Journal 2013; 34: 2949-3003.
  21. Moya A, Sutton R, Ammirati F et al. Guidelines for the diagnosis and management of syncope (version 2009). The Task Force for the diagnosis and management of syncope of the European Society of Cardiology (ESC). European Heart Journal 2009; 30: 2631-2671.
  22. National Imaging Associates, Inc. Clinical Guidelines. Myocardial Perfusion Imaging (aka Nuclear Cardiac Imaging Study), 2018.
  23. Ridker PM, Buring JE, Fifai N. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds risk score. Journal of the American Medical Association 2007; 297(6): 611-619.Schwartz PJ, Crotti L. QTc behavior during exercise and genetic testing for the long-QT syndrome. Circulation 2011; 124(20): 2181-4.
  24. Wolk MJ, Bailey SR, Doherty JU et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. Journal of the American College of Cardiology 2014; 63(4): 380-406.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/26/18.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

12/15/07

2008 ICD-9 CM update. Added ICD-9 diagnosis 414.2 for CPT codes 78460, 78461, 78464, 78465, 78469, 78472, 78473, 78481, 78483, 78494, and 78496. Added 440.4 for CPT codes 78460, 78461, 78464, 78465, and 78469. Medicare Advantage, added ICD-9 diagnosis 414.2 and 440.4 for CPT codes 78460, 78461, 78464, and 78465; and added ICD-9 diagnosis 414.2 for CPT codes 78472, 78473, 78481, 78483, 78494, and 78496.

01/21/08

Updated Program Exceptions.

05/15/08

Scheduled review. No change in position statements. Deleted ICD-9 diagnosis codes that support medical necessity. Updated references.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Annual HCPCS coding update: deleted 78460, 78461, 78464, 78465, 78478, and 78480; added 78451, 78452, 78453, and 78454. Revised BCBSF Radiology Management program exception, and updated the references.

05/15/10

Revised position statement. Added Medicare Advantage program exception. Updated references.

09/15/11

Scheduled review; revised guideline name, deleted “radionuclide” and added “nuclear”. Revised position statements. Revised reimbursement information. Updated Medicare Advantage products program exception. Updated definitions. Updated references.

10/01/11

Revision; formatting changes.

01/15/13

Annual review; revised position statements, added criteria for: evaluation for suspected CAD, detection of CAD, evaluation for known CAD and risk assessment (acute coronary syndrome, post revascularization, viability/ischemia-ischemic cardiomyopathy). Revised Medicare Advantage products program exception (format changes). Updated references.

01/01/14

Review. Updated program exception.

07/08/15

Updated program exception.

10/15/16

Revision; Removed cardiac blood pool imaging from subject. Revised position statement. Deleted codes (78472, 78473, 78494 and 78496). Revised reimbursement information and program exceptions. Updated related guidelines and references.

12/15/17

Revision; format changes.

05/15/18

Revision; revised position statement. Revised suspected coronary artery disease (CAD): asymptomatic high global risk. Deleted syncope; coronary artery disease (CAD) in the presence of other new cardiac concerns. Updated references.

Date Printed: May 21, 2018: 02:32 PM