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Date Printed: June 28, 2017: 11:52 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-78000-21

Original Effective Date: 10/15/16

Reviewed: 09/22/16

Revised: 00/00/00

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Multiple-Gated Acquisition (MUGA) Scan

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:

Multiple-gated acquisition (MUGA) scanning is a radionuclide ventriculography technique used to evaluate the pumping function of the ventricles of the heart. During this noninvasive nuclear imaging test, a radioactive tracer is injected into a vein and a gamma camera detects the radiation released by the tracer, providing moving images of the heart. From these images, the health of the heart’s pumping chamber (left ventricle) can be assessed. MUGA scanning is used to evaluate the left ventricular ejection fraction (LVEF), a measure of overall cardiac function. It may also detect areas of poor contractility following an ischemic episode and it is used to evaluate left ventricular hypertrophy.

POSITION STATEMENT:

Multiple-gated acquisition (MUGA) scan meets the definition of medical necessity for the following indications:

• Evaluation of left ventricular (LV) functions at baseline before chemotherapy or cardiotoxic chemotherapy; may be repeated prior to subsequent chemotherapy cycles until a total cardiotoxic dose has been reached

• Evaluation of ejection fraction in a member with congestive heart failure (CHF)

• Evaluation of a member, who is obese or who has chronic obstructive pulmonary disease (COPD), for coronary artery disease (CAD)

• As an alternative form of stress imaging instead of echocardiography or myocardial perfusion imaging for the evaluation of coronary or valvular heart disease

Combination of Studies with MUGA:

Abdomen CT/Pelvis CT/Chest CT/Neck MRI/Neck CT with MUGA

• Known tumor/cancer for initial staging or evaluation before starting chemotherapy or radiation treatment

Additional Information Related to MUGA:

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 indicates why additional imaging is needed for the type and area(s) requested.

MUGA Scan Monitoring During Chemotherapy

Chemotherapeutic drugs that are used in cancer treatment may be toxic to the heart muscle. To minimize the risk of damaging the heart muscle with these drugs, the member’s cardiac function may be monitored with the MUGA scan before and during administration of the drug. Before the first dose of the drug, a MUGA scan may be performed to establish a baseline left ventricle ejection fraction (LVEF). It may then be repeated after cumulative doses. If the LVEF begins to decrease, cardio toxicity risk must be considered if continuing the treatment.

BILLING/CODING INFORMATION:

CPT Coding:

78472

Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing

78473

Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification

78494

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

78496

Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

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 multiple-gated acquisition (MUGA) scan.

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 BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the member’s contract benefits.

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

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Cardiac Nuclear Imaging (Myocardial Perfusion Imaging), 04-78000-19

OTHER:

Other names used to report multiple-gated acquisition (MUGA) scan:

Blood pool scan

Equilibrium radionuclide angiogram

First pass

Multi-gated acquisition (MUGA) scan

REFERENCES:

  1. Anagnostopoulos C, Harbinson M, Kelion A et al. Procedure guidelines for radionuclide myocardial perfusion imaging. Heart 2004; 90 (Suppl. I):i1–i10.
  2. Berman DS, Kang X, Hayes SW et al. Adenosine myocardial perfusion single-photon emission computed tomography in women compared with men. Impact of diabetes mellitus on incremental prognostic value and effect on patient management. Journal of the American College of Cardiology 2003; 41(7): 1125-1133.
  3. Fihn SD, Blankenship JC, Alexander KP et al. ACC/AHA/AATS/PCNA/SCAI/STS Focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Journal of the American College of Cardiology 2014; 64(18): 1929-1949.
  4. Hachamovitch R, Hayes SW, Friedman JD et al. Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. Journal of the American College of Cardiology 2004; 43(2): 200-208.
  5. Hacker M, Jakobs T, Matthiesen F et al. Comparison of Spiral Multidetector CT Angiography and Myocardial Perfusion Imaging in the Noninvasive Detection of Functionally Relevant Coronary Artery Lesions: First Clinical Experiences. Journal of Nuclear Medicine 2005; 46:1294–1300.
  6. Hakeem A, Bhatti S, Dillie KS et al. Predictive value of myocardial perfusion single-photon emission computed tomography and the impact of renal function on cardiac death. Circulation 2008; 118(24): 2540-2549.
  7. Karkos CD, Thomson GJL, Hughes R et al. Prediction of cardiac risk before abdominal aortic reconstruction: Comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction. Journal of Vascular Surgeons 2002; 35(5): 943-949.
  8. Marcassa C, Bax JJ, Genge F et al. Clinical value, cost-effectiveness, and safety of myocardial perfusion scintigraphy: a position statement. European Heart Journal 2008; 29, 557–563.
  9. National Imaging Associates, Inc. MUGA Scan Clinical Guideline, 2016.
  10. Shureiqi I, Cantor SB, Lippman SM et al. Clinical and economic impact of multiple gated acquisition scan monitoring during anthracycline therapy. British Journal of Cancer 2002; 86, 226 – 232
  11. 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 09/22/16.

GUIDELINE UPDATE INFORMATION:

10/15/16

New Medical Coverage Guideline.

Date Printed: June 28, 2017: 11:52 PM