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04-70540-13

Original Effective Date: 07/01/07

Reviewed:04/26/18

Revised:05/15/18

Subject: Magnetic Resonance Imaging (MRI) Cardiac

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 Update    
           

DESCRIPTION:

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique used to produce high quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low osmolar contrast media, ionic and high osmolar contrast media) are used to enable visualization of a body system or body structure.

The U.S. Food and Drug Administration’s (FDA) cleared MRI systems for marketing through the 510(k) process. The Fonar Stand-Up MRI system received FDA marketing clearance in October 2000.

POSITION STATEMENT:

INDICATIONS FOR CARDIAC (HEART) MRI:

Where stress echocardiography (SE) is noted as an appropriate substitute according to the American College of Cardiology Foundation (ACCF) Appropriateness Criteria for cardiac magnetic resonance imaging (MRI) for* indications (2, 3, 4, 12, and 13) AND at least one of the following contraindications to SE must be documented in the member’s medical record:

OR

Cardiac MRI is the preferred diagnostic imaging to stress echocardiography for the following, including, but not limited to following conditions:

OR

All other requests for cardiac MRI, the member must meet the ACCF cardiac magnetic resonance imaging Appropriateness Criteria Score (4-9).

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM APPROPRIATE USE CRITERIA for CARDIAC MRI:

*Detection of CAD: Symptomatic

Heart MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

Refer to reimbursement information section.

Detection of CAD Symptomatic- Evaluation of Chest Pain Syndrome, Including Low Risk Unstable Angina (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

2 U (4)

  • Intermediate pre-test probability of CAD
  • ECG interpretable and able to exercise

3 A (7)

  • Intermediate pre-test probability of CAD
  • ECG uninterpretable or unable to exercise

4 A (7-9)

  • High pre-test probability of CAD

Follow-up of Known Ischemic CAD

Asymptomatic or Stable Symptoms

4a A (7-9)

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 CMR in members with high risk clinical scenarios, such as left ventricular dysfunction (ejection fraction less than 50%) or severe unrevascularized 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).

New, recurrent, or worsening (progressive) symptoms in members with known ischemic CAD

4b A (7-9)

Prior low risk coronary evaluation at least two years earlier (e.g. limited extent of coronary artery disease, <5% myocardium at risk), and now with new stable (or low risk unstable), recurrent, or slowly worsening (progressive) symptoms of coronary ischemia, is an appropriate indication for stress CMR in this member group. However, regardless of timing of prior non-invasive assessment, clinical documentation of continued problematic symptoms or moderate to highly likely acute coronary syndrome (Table 3) of even low mortality risk (Table 4) is often better assessed with invasive coronary arteriography, particularly when stress testing in the last 2 years and current clinical findings are at odds. This category is very documentation-sensitive and requires judgment.

Note: Invasive coronary arteriography is generally preferable in those members, who have a prior moderate or high risk stress test result (especially if not previously evaluated by invasive coronary arteriography) or a current diagnosis of moderate to high risk unstable angina, and inappropriate for repeat stress CMR unless supervening reasons to prefer a non-invasive approach are documented in the record (e.g. very unclear symptoms, CKD, dye allergy), and it could alter management.

New, recurrent, or worsening (progressive) symptoms in members with known ischemic CAD

4b A (7-9)

Prior low risk coronary evaluation at least two years earlier (e.g. limited extent of coronary artery disease, <5% myocardium at risk), and now with new stable (or low risk unstable), recurrent, or slowly worsening (progressive) symptoms of coronary ischemia, is an appropriate indication for stress CMR in this member group. However, regardless of timing of prior non-invasive assessment, clinical documentation of continued problematic symptoms or moderate to highly likely acute coronary syndrome (Table 3) of even low mortality risk (Table 4) is often better assessed with invasive coronary arteriography, particularly when stress testing in the last 2 years and current clinical findings are at odds. This category is very documentation-sensitive and requires judgment.

Note: Invasive coronary arteriography is generally preferable in those members, who have a prior moderate or high risk stress test result (especially if not previously evaluated by invasive coronary arteriography) or a current diagnosis of moderate to high risk unstable angina, and inappropriate for repeat stress CMR unless supervening reasons to prefer a non-invasive approach are documented in the record (e.g. very unclear symptoms, CKD, dye allergy), and it could alter management.

New or Worsening Symptoms without Known CAD

4c A (7-9)

ONE of the following, when invasive coronary arteriography is not clearly indicated or appropriate (e.g., data are equivocal, symptoms not clear, CKD, dye allergy, other etiologies suspect):

  • Normal exercise EKG
  • CCTA, invasive coronary arteriography, or stress imaging did not show obstructive CAD Symptoms

4d U (4-6)

  • Abnormal prior stress imaging study, when invasive coronary arteriography is not clearly indicated or appropriate (e.g., data are equivocal, symptoms not clear, CKD, dye allergy, other etiologies suspect):
  • Post Coronary Revascularization

4e A (7-9)

  • Symptomatic or schemic equivalent that is well documented

4f A (7-9)

  • Asymptomatic

Minimum of 2 years post coronary artery bypass grafting or 2 years post percutaneous coronary intervention (whichever was the latter) is appropriate only for members with high direct coronary related risk, such as incomplete coronary revascularization with feasible additional revascularization of residual severe multivessel disease, need for otherwise unevaluated follow up of stenting of unprotected left main (LM) coronary artery disease or left ventricular dysfunction (ejection fraction less than 50%), or for members with high occupational risk (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 high personal risk (e.g. scuba divers).

  • Evaluation of asymptomatic member

4g U (4-6)

  • High global risk CAD
  • Regardless of EKG interpretability or ability to exercise >2 years from last assessment

Evaluation of Intra-Cardiac Sturctures (Use of MR Coronary Angiography)

8 A(8)

  • Evaluation of suspected coronary anomalies or coronary aneurysms

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR

12 U (6)

  • Intermediate global risk
  • Equivocal stress imaing test (exercise, stress SPECT, or stress echocardiography)

13 A (7)

  • Coronary angiography (catherization or CCTA)
  • Stenosis of unclear significance

13a A (7-9)

  • Prior exercise EKG stress test or CCTA
  • Equivocal result

13b A (7-9)

ONE of the following:

  • High concern for ischemic EKG with intermediate to high global risk EKG, and indication for invasive coronary arteriography is not clear
  • Abnormal prior exercise EKG with preference to avoid invasive evaluation (e.g., unclear symptoms, midly abnormal stress EKG, dye allergy, CKD)
  • Obstructive CAD on prior CCTA and either physiologic evaluation for ischemia is required, or there are new or worsening symptoms.
  • Obstructive CAD on invasive coronary angiography and physiologic evaluation for ischemia is required
  • Left bundle branch block, when the history (intermediate to high global risk), physical examination, and/or noninvasive ejection fraction together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress CMR

13c U (4-6)

ONE of the following:

  • High concern for ischemic EKG, but only low global risk coronary artery disease, and indication for invasive coronary arteriography is not clear
  • Abnormal prior stress imaging study and indication for invasive coronary arteriography is not clear
  • Left bundle branch block, when the history (low global risk), physical examination, and/or noninvasive ejection fraction together support further evaluation, and invasive coronary arteriography is not already indicated, is an indication for stress CMR

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery –Intermediate or High Risk Surgery (Use of Vasodilator Perfusion CMR or

Dobutamine Stress Function CMR)

15a A (7-9)

If ALL the following apply:

  • Coronary evaluation before thoracoabdominal aortic surgery
  • Member has less than a 4 MET functional capacity
  • Member has one peri-operative risk factor
  • No coronary evaluation (invasive or non-invasive) within the past year
  • If invasive coronary arteriography is preferable, then stress CMR is not appropriate
  • Alternatively, without the need for the above criteria, member would be a candidate for stress CMR at the time of a preoperative evaluation if indications unrelated to the surgery were well documented in the clinical record

Other Cardiovascular Conditions

15a A(7-9)

ONE of the following:

  • Newly diagnosed systolic heart failure
  • Newly diagnosed diastolic heart failure
  • Sustained VT
  • VF
  • Exercise induced VT or nonsustained VT
  • Prior to initiation of antiarrhythmic therapy in high CAD global risk members

15b U(4-6)

ONE of the following:

  • Frequent PVCs (>30 min)
  • Intermediate or high global risk CAD

Structure and Function

Heart MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to additional information section)

Valvular Structure and Function

Evaluation of Ventricular and Valvular Function

Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease and delayed contrast enhancement, when echocardiogram is inadequate

18 A (9)

  • Assessment of complex congenital heart disease including anomalies of coronary circulation, great vessels, and cardiac chambers and valves
  • Procedures may include LV/RV mass and volumes, MR angiography, quantification of valvular disease, and contrast enhancement

18a A (8)

  • Severe tricuspid regurgitation and suboptimal TTE images, for assessment of RV systolic function and systolic and diastolic volumes
  • Alternative imaging modality: CCT (U (6))

18b A (7)

  • Severe MR suspected clinically, potentially underestimated on TTE despite optimal images; better imaging of MR jet needed
  • Alternative imaging modality: TEE (A (9))

18c A (7)

  • In chronic asymptomatic member, to distinguish between moderate or severe primary MR, when TTE images are inadequate
  • Alternative imaging modality: TEE

18d A (7)

  • Discordance between clinical assessment and TTE about the severity of AR, when TTE images are inadequate
  • Alternative imaging modality: TTE (A (8)), CCT (A (9))

18e A (7)

  • Pre TAVR assessment of aortic annular size and shape
  • Alternative imaging modality: TEE (A (7), CCT (A (9))

18f A (7)

  • Pre TAVR assessment of aortic dimensions
  • Alternative imaging modality: CCT (A (9))

19 U (6)

  • Evaluation of LV function following myocardial infarction OR in heart failure members

20 A (8)

  • Evaluation of LV function following myocardial infarction OR in heart failure members
  • Members with technically limited images from echocardiogram

21 A (8)

  • Quantification of LV function
  • Discordant information that is clinically significant from prior tests

22 A (8)

  • Evaluation of specific cardiomyopathies (infiltrative (amyloidosis, sarcoidosis, hemochromatosis), noncompaction, hypertrophic cardiomyopathy (HCM), acute viral myocarditis or due to cardiotoxic therapies), if echocardiography is inadequate and the information might alter management
  • Use of delayed enhancement

23 A (8)

  • Characterization of native and prosthetic cardiac valves—including morphology of a bicuspid aortic valve’s ascending aorta, hemodynamics, planimetry of stenotic disease, quantification of regurgitant disease, preoperative/pre-interventional evaluation of septal defects, and valve/inflow/outflow/conduit dimensions, necessary evaluation of congenital heart disease (e.g., anomalous pulmonary venous return, tetralogy of Fallot)
  • Members with technically limited images from echocardiogram, transesophageal echocardiogram, or cardiac CT

23a A (8)

  • Re-evaluation (<1 y) of the size and morphology of the aortic sinuses and ascending aorta in members with a bicuspid AV and an ascending aortic diameter >4 cm with 1 of the following:
  • Aortic diameter >4.5 cm
  • Rapid rate of change in aortic diameter
  • Family history (first-degree relative) of aortic dissection
  • Alternative imaging modality: CCT (A (8)), TTE (A (7))

23b A (7)

  • Characterization of bioprosthetic valve if suspected clonically significant valvular dysfunction and inadequate images from TTE and TEE
  • Alternative imaging modality: CCT (A (7))

23c U (5)

  • Characterization of mechanical prosthetic valve if suspected clinically significant valvular dysfunction and inadequate images from TTE and TEE
  • Alternative imaging modality: CCT: (A (7)), flurosocpy (A (7))

24 A (9)

  • Evaluation for arrhythmogenicc right ventricular cardiomyopathy (ARVC)
  • Members presenting with syncope or ventricular arrhythmia

25 A (9)

  • Evaluation of myocarditis or myocardial infarction with normal coronary arteries
  • Positive cardiac enzymes without obstructive atherosclerosis on angiography

Evaluation of Intra-and Extra- Cardiac Structures

26a U (6)

  • Suspected cardiac mass, suspected tumor or thrombus, or potential cardiac source of emboli, when TTE images are inadequate
  • Alternative imaging modality: TTE (A (9)), TEE (A (7))
  • Use of contrast for perfusion and enhancement

26b A (9)

  • Detailed evaluation of a known cardiac mass (tumor or thrombus, most often previously noted on echocardiography)
  • Use of contrast for perfusion and enhancement

27 A (8)

  • Evaluation of pericardial conditions (pericardial mass, constrictive, pericarditis, contriction versus restrictive cardiomyopathy

28 A (8)

  • Evaluation for aortic dissection

29 A (8)

  • Evaluation of pulmonary veins prior to radiofrequency ablation for atrial fibrillation
  • Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes

Detection of Myocardial Scar and Viability

Heart MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score

A= Appropriate (7-9)

U= Uncertain (4-6)

Indications

(*Refer to additional information section)

Detectiom of Myocardial Scar and Viability- Evaluation of Myocardial Scar (Use of Late Gadolinium Enhancement)

30 A (7)

  • To determine the location, and extent of myocardial necrosis including “no reflow” regions
  • Post acute myocardial infarction

31 U (4)

  • To detect post PCI myocardial necrosis

32 A (9)

  • To determine viability prior to revascularization
  • Establish likelihood of recovery of function with revascularization (PCI or CABG) or medical therapy

33 A (9)

  • To determine viability prior to revascularization
  • Viability assessment by SPECT or dobutamine echo has provided “equivocal or indeterminate” results”

INAPPROPRIATE INDICATIONS:

Indications in the American College of Cardiology Foundation (ACCF) Appropriateness Criteria for cardiac magnetic resonance imaging with an Appropriate Use Score (1-3; Inappropriate (I)) OR any one of the following do not meet the definition of medically necessity:

INAPPROPRIATE USE INDICATIONS

Detection of CAD: Symptomatic

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score)

Indications

(Refer to additional information section.)

Appropriate Use Score (1-3)

I= Inappropriate

Detection of CAD: Symptomatic

Evaluation of Chest Pain Syndrome (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

1

  • Low pre-test probability of CAD
  • ECG interpretable AND able to exercise

I (2)

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

5

  • Intermediate pre-test probability of CAD
  • ECG interpretable AND able to exercise

I (2)

6

  • Intermediate pre-test probability of CAD
  • ECG uninterpretable OR unable to exercise

I (2)

7

  • High pre-test probability of CAD

I (1)

Acute Chest Pain (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

10

  • High pre-test probability of CAD
  • ECG - ST segment elevation and/or positive cardiac enzymes

I (1)

Risk Assessment With Prior Test Results (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

11

  • Normal prior stress test (exercise, nuclear, echo, MRI)
  • High CHD risk (Framingham)
  • Within 1 year of prior stress test

I (2)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery – Low Risk Surgery (Use of Vasodilator Perfusion CMR or Dobutamine Stress Function CMR)

14

  • Intermediate perioperative risk predictor

I (2)

Detection of CAD: Post-Revascularization (PCI or CABG)

Cardiac MRI

(Appropriate ACCF/ASNC/ACR/AHA /ASE/SCCT/SCMR/SNM Criteria

# with Use Score)

Indications

(*Refer to additional information section.)

Appropriate Use Score (1-3)

I= Inappropriate

Detection of CAD: Post-Revascularization (PCI or CABG)

Evaluation of Chest Pain Syndrome (Use of MR Coronary Angiography)

16

  • Evaluation of bypass grafts

I (2)

17

  • History of percutaneous revascularization with stents

I (1)

BILLING/CODING INFORMATION:

CPT Coding

75557

Cardiac magnetic resonance imaging for morphology and function without contrast material;

75559

Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging

75561

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

75563

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

75565

Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)

HCPCS Coding

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for cardiac magnetic resonance imaging (75557, 75559, 75561, 75563, and 75565) is limited to one (1) cardiac magnetic resonance imaging within a 6-month period. Cardiac magnetic resonance imaging in excess of one (1) within a 6-month period is subject to medical review for medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

Re-imaging or additional imaging due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

Request for a follow-up study

A follow-up study may be needed to help evaluate a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Open MRI Units (Stand-Up MRI/Sitting MRI-Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing (Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

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 magnetic resonance imaging (MRI) cardiac.

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

Determination of Pretest Probability for Coronary Artery Disease (CAD)

Table 1: Determination of Pretest Probability for Coronary Artery Disease Based on Age, Gender, and Symptoms (Source: American College of Cardiology Criteria for Pretest Probability of Coronary Artery Disease (CAD).

The following risk assessment may be used to determine pre-test probability of coronary artery disease.

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

High: Greater than 90% pre-test probability of CAD

Intermediate: Between 10% and 90% pre-test probability of CAD

Low: Between 5% and 10% pre-test probability of CAD

Very low: Less than 5% pre-test probability of CAD

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

Typical Angina (Definite): 1.) Substernal chest pain or discomfort that is 2.) Provoked by exertion or emotional stress and 3.) Relieved by rest and/or nitroglycerine.

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

Non-Anginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Coronary Heart Disease (CHD) Risk

Table 2: Framingham Risk Assessment for Coronary Heart Disease (CHD) Risk

Framingham risk assessment is a calculation to predict the 10-year risk of heart disease. The calculation is based on the individual’s age, sex, most recent lipid values, blood pressure, smoking history, and presence of diabetes.

CHD Risk Level

Framingham Score

CHD Risk-Low Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk.

Less than 10%

CHD Risk-Moderate Defined by the age-specific risk level that is average or above average.

Between 10% and 20%

CHD Risk-High Defined as the presence of diabetes mellitus.

Greater than 20%

Determining Preoperative Risk

*Perioperative Risk Predictors

As defined by the *ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation of Non-Cardiac Surgery

Major risk predictors

  • Unstable coronary syndromes, decompensated heart failure (HF), significant arrhythmias, and severe valve disease.

Intermediate risk predictors

  • Mild angina, prior myocardial infarction (MI), compensated or prior HF, diabetes, or renal insufficiency.

Minor risk predictors

  • Advanced age, abnormal electrocardiogram (ECG), rhythm other than sinus, low functional capacity, history of cerebrovascular accident, and uncontrolled hypertension.

*Surgical Risk Categories

As defined by the *ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation of Non-Cardiac Surgery)

High-Risk Surgery—cardiac death or MI greater than 5%

  • Emergent major operations (particularly in the elderly), aortic and peripheral vascular surgery, prolonged surgical procedures associated with large fluid shifts and/or blood loss.

Intermediate-Risk Surgery—cardiac death or MI = 1% to 5%

  • Carotid endarterectomy, head and neck surgery, surgery of the chest or abdomen, orthopedic surgery, prostate surgery.

Low-Risk Surgery—cardiac death or MI less than 1%

  • Endoscopic procedures, superficial procedures, cataract surgery, breast surgery.

ECG–Uninterpretable

Refers to ECGs with resting ST-segment depression (greater than or equal to (≥) 0.10 mV), complete LBBB, pre-excitation (Wolff-Parkinson-White Syndrome), or paced rhythm.

Table 3

Likelihood that Signs and Symptoms Indicate an acute coronary syndrome (ACS Secondary to coronary artery disease (CAD)

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 previously documented angina

Known history of CAD, including MI

Chest or left arm pain or discomfort as chief symptom

Age ≥ 70 years

Male sex

Diabetes

Probable ischemic symptoms in absence of any of the intermediate likelihood characteristics

Recent cocaine use

Examination

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

Extracardiac vascular disease

Chest discomfort reproduced by palpation

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

Normal ECG tracing

ECG

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

Fixed Q waves

ST depression of 0.5-1.0 mm or T-wave inversion >1.0 mm

 

Cardiac markers

Elevated cardiac TnI, TnT, or CK-MB levels

Normal

Normal

ACS = acute coronary syndrome; CAD = coronary artery disease; CK-MB = muscle and brain fraction of creatine kinase; ECG = electrocardiography; MI =myocardial infarction; MR = mitral regurgitation; TnI = troponin I; TnT = troponin T.

Adapted from: Kumar A, Cannon CP. Acute Coronary Syndromes: Diagnosis and Management, Part I. Mayo Clinic Proceedings 2009; 84(10): 917-938

Table 4

Short Term Risk of Death or Nonfatal myocardial infarction (MI) in Acute Coronary Syndrome (ACS)

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

History

Accelerating tempo of ischemic symptoms in preceding 48 hour

Previous MI, peripheral or cerebrovascular disease, or CABG; previous aspirin use

 

Character of pain

Prolong ongoing (>20 min) resting pain

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

Rest angina (>20 min) or relieved with rest or sublingual nitroglycerin

Nocturnal angina

New-onset or progressive CCS class III or IV angina in the past 2 weeks without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD

Increased angina frequency, severity, or duration

Angina provoked at a lower threshold

New-onset angina with onset 2 weeks to 2 months before presentation

Clinical findings

Pulmonary edema, most likely because of ischemia

New or worsening MR murmur S3 or new/worsening rales

Hypotension, bradycardia, tachycardia

Age ≥75 years

Age ≥70 years

 

ECG

Angina at rest with transient ST-segment changes >0.5 mm

Bundle branch block, new or presumed new

Sustained ventricular tachycardia

T wave changes

Pathologic Q waves or resting ST-depression <1 mm in multiple lead groups (anterior, inferior, lateral)

Normal or unchanged findings on ECG

Cardiac markers

Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT, or TnI >0.1 ng/mL)

Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 ng/mL)

Normal

CABG= coronary artery bypass graft; CAD= coronary artery disease; CCS= Canadian Cardiovascular Society; CK-MB= muscle brain fraction of creatine kinase; ECG= electrocardiography; MI= myocardial infarction; MR= mitral regurgitation; NSTEMI= non-ST-elevation myocardial infarction

Adapted from: Kumar A, Cannon CP. Acute Coronary Syndromes: Diagnosis and Management, Part I. Mayo Clinic Proceedings 2009; 84(10): 917-938

Anginal or Ischemic 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, etc.), by presentation of clinical data such as respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and 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.

Exercise Treadmill Testing

Exercise Treadmill Testing (ETT) is the appropriate first line test in most patients with suspected CAD. In appropriately selected patients the test provides adequate sensitivity and specificity with regard to diagnosis and prognostication. There are patients in whom the test is not the best choice, for example those with resting ECG abnormalities, inability to exercise and perhaps diabetes. Also of note from an operational standpoint the test does not require pre-authorization.

An uninterpretable baseline EKG includes:

Abnormalities of ST segment depression of 0.1 mV (1 mm with conventional calibration) or more

Ischemic looking T wave inversions of at least 0.25 mV (2.5 mm with conventional calibration)

EKG findings of probable or definite LVH, WPW, a ventricular paced rhythm, or left bundle

branch block

Digitalis use or hypokalemia

Resting HR under 50 bpm on a beta blocker and an anticipated suboptimal workload (e.g. ratepressure

product less than 20-25K)

Prior false positive stress EKG

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 (METs) 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

If a patient has not had a recent exercise test before noncardiac surgery, functional status can usually be estimated from activities of daily living. Functional capacity is often expressed in terms of metabolic equivalents (METs), where 1 MET is the resting or basal oxygen consumption of a 40–year old, 70-kg man. In the perioperative literature, functional capacity is classified as excellent (>10 METs), good (7 METs to 10 METs), moderate (4 METs to 6 METs), poor (<4 METs), or unknown. Perioperative cardiac and long-term risks are increased in patients unable to perform 4 METs of work during daily activities. Examples of activities associated with <4 METs are slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at approximately 2 mph to 3 mph. Examples of activities associated with >4 METs are climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house. Source: Fleisher LA, Fleischmann KE, Auerbach AD et al. ACC/AHA Clinical Practice Guideline 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. Circulation 2014; 130: e278-e333

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

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:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Brachial plexopathy: any neuropathy of the brachial plexus, also called brachial plexus neuropathy, brachial syndrome, and cervicobrachial syndrome.

Cardiomyopathies: a general diagnostic term designating primary noninflammatory disease of the heart muscle, often of obscure or unknown etiology and not the result of ischemic, hypertensive, congenital, valvular, or pericardial disease. Cardiomyopathies are usually subdivided into dilated, hypertrophic, and restrictive.

Myocardial infarction: gross necrosis of the myocardium as a result of interruption of the blood supply to the area; it is almost always caused by atherosclerosis of the coronary arteries, upon which coronary thrombosis is usually superimposed.

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.

RELATED GUIDELINES:

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck, 04-70540-12

Magnetic Resonance Imaging (MRI) Abdomen and Pelvis, 04-70540-14

Magnetic Resonance Imaging (MRI) Upper Extremity, 04-70540-15

Magnetic Resonance Imaging (MRI) Lower Extremity, 04-70540-16

Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar), 04-70540-17

OTHER:

Other names used to report MRI:

Nuclear Magnetic Resonance (NMR)
Open MRI

Other names used to report Positional MRI:

Position MRI (pMRI)
Sitting MRI
Stand-Up MRI
Standing MRI
Weight-bearing MRI

Abbreviations

ACCF = American College of Cardiology Foundation

ACS = acute coronary syndrome

ACR = American College of Radiology

AR= aortic regurgitation

ARVC= arrhythmogenicc right ventricular cardiomyopathy

ASNC = American Society of Nuclear Cardiology

BMI = body mass index

CABG = coronary artery bypass grafting surgery

CAD = coronary artery disease

CCT= cardiac computed tomography

CCTA = coronary CT angiography

CHD = coronary heart disease

CHF = congestive heart failure

CKD= chronic kidney disease

CMR= cardiac magnetic resonance

CT = computed tomography

CTA = computed tomographic angiography

ECG/EKG = electrocardiogram

ERNA = equilibrium radionuclide angiography

FEV1 = forced expiratory volume

FFR= fractional flow reserve

FP = First Pass

GOLD = Global initiative for chronic obstructive lung disease

HF = heart failure

LBBB = left bundle-branch block

LV = left ventricular/ left ventricle

LVH=Left ventricular hypertrophy

MET = estimated metabolic equivalent of exercise

MI = myocardial infarction

MPI = myocardial perfusion imaging

MR= mitral regurgitation

MRA = magnetic resonance angiography

MRI = magnetic resonance imaging

NASCI = North American Society for Cardiac Imaging

PCI = percutaneous coronary intervention

PET = positron emission tomography

PVC= premature ventricular contraction

RNA = radionuclide angiography

RV= right ventricular

SCAI = Society for Cardiovascular Angiography and Interventions

SCCT = Society for Cardiovascular Magnetic Resonance

SE = stress echocardiography

SIR = Society of Interventional Radiology

SPECT = single positron emission CT (see MPI)

TEE= transesophageal echocardiography

TTE= transthoracic echocardiogram

VF= ventricular tachycardia

VT= ventricular tachycardia

WPW= Wolff-Parkinson-White syndrome

REFERENCES:

  1. ACR-NASCI-SPR Practice Parameter for the Performance and Interpretation of Cardiac Magnetic Resonance Imaging (MRI), Revised 2016.
  2. Blue Cross Blue Association Positional Magnetic Resonance Imaging (MRI) 6.01.48, 03/17.
  3. Doherty JU, Kort S, Mehran R et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate use criteria for multimodality imaging in valvular heart disease. Journal of the American College of Cardiology 2017.
  4. Fleisher LA, Fleischmann KE, Auerbach AD et al. ACC/AHA Clinical Practice Guideline 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. Circulation 2014; 130: e278-e333.
  5. Hendel RC, Patel MR, Kramer CM et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. Journal of the American College of Cardiology 2006; 48(7): 1475-1497.
  6. Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, Part I. Mayo Clinic Proceedings 2009; 84(10): 917-938.
  7. National Imaging Associates, Inc. Clinical Guidelines MRI Heart, 2018.

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.

01/01/08

HCPCS update. Deleted 75552, 75553, 75554, 75555, and 75556. Added 75557, 75558, 75559, 75560, 75561, 75562, 75563, and 75564.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled review. No change in position statement. Updated references and related Internet links.

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.

11/15/09

Code update; added 71552.

01/01/10

Annual HCPCS coding update: deleted 75558, 75560, 75562, and 75564. Added 75565. Revised BCBSF Radiology Management program exception section, and updated the references.

07/15/10

Annual review: deleted 77084 and updated references.

09/15/11

Scheduled review; revised position statements. Deleted 77084. Updated definitions and references.

10/01/11

Revision; formatting changes.

12/15/12

Annual review; added indications for chest and cardiac MRI and appropriate use criteria and table for cardiac MRI. Added inappropriate indications for cardiac MRI. Added criteria for imaging which exceed limit. And statement for re-imaging or additional imaging. Added Medicare Advantage program exception (nationally non-covered indications) for MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications. Updated references.

01/01/14

Review. Updated program exception and references.

01/01/15

Scheduled review; maintain position statement. Updated references.

05/15/18

Revision; removed “chest and” from guideline title, revised position statement and updated references.

Date Printed: May 27, 2018: 07:42 PM