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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.

04-78000-16

Original Effective Date: 06/15/01

Reviewed: 12/05/13

Revised: 04/15/17

Subject: Positron Emission Tomography (PET Scan) Cardiac Applications

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:

Positron emission tomography (PET) scans are based on the use of positron emitting radionuclide tracers, which simultaneously emit 2 high energy photons in opposite directions. These photons can be simultaneously detected (referred to as coincidence detection) by a PET scanner, consisting of multiple stationary detectors that encircle the thorax. Compared to SPECT scans (single photon emission computed tomography), coincidence detection offers greater spatial resolution.

A variety of radiopharmaceuticals (tracers, radiotracers) are used for PET scanning, (e.g., e.g., ammonia N-13, Fluorodeoxyglucose F-18 FDG, Rubidium Rb-82). Because of their short half-life, radiopharmaceuticals must be made locally. With the exception of fluorine and rubidium, radiopharmaceuticals must be manufactured with an on-site cyclotron. The radiopharmaceutical may be coupled to a variety of physiologically active molecules. For example, fluorine-18 is often coupled with fluorodeoxyglucose as a means of detecting glucose metabolism, which in turn reflects the metabolic activity, and thus viability, of the target tissue.

In terms of cardiac applications, PET scanning has focused on the following clinical situations: myocardial perfusion scanning as a technique of identifying perfusion defects, which in turn reflect coronary artery disease; and assessment of myocardial viability in patients with left ventricular dysfunction as a technique to determine candidacy for a revascularization procedure.

POSITION STATEMENT:

Myocardial Perfusion Positron Emission Tomography (PET) Imaging

Myocardial perfusion PET imaging may be considered when a member has undergone prior nuclear stress testing (e.g., thallium stress test) or stress echocardiography with equivocal results.

Myocardial perfusion PET imaging is performed in lieu of, but not in addition to a single photon emission computed tomography (SPECT).

In extreme obese members (*BMI > 40kg/m2) or silicone breast implants, myocardial perfusion PET imaging may be considered as the initial test (because of a higher likelihood of technically suboptimal image quality on nuclear stress testing and stress echocardiography in this population). *As defined by the National Heart Lung and Blood Institute Classification of Overweight and Obesity by BMI.

Myocardial perfusion PET imaging (rest and or stress) meets the definition of medically necessity for the following indications for patients who are at least 65 years old OR have a body mass index (BMI) greater than 40 or other conditions for which a SPECT may have attenuation problems because of the likelihood of technically suboptimal image quality on nuclear stress testing and stress echocardiography in this patient population (e.g., large breasts, left mastectomy, breast implant, chest wall deformity) AND when the results are expected to influence the clinical management of the member with any of the following:

Myocardial perfusion PET imaging (rest and or stress) does not meet the definition of medical necessity for screening for coronary artery disease.

Myocardial Metabolic Positron Emission Tomography (PET) Imaging

Myocardial metabolic PET imaging for evaluation of myocardial viability meets the definition of medically necessity when ALL of the following conditions are met and when the results are expected to influence the clinical management of the member.

Myocardial metabolic PET imaging does not meet the definition of medical necessity for screening for coronary artery disease.

Documentation Requirements

Documentation containing the medical necessity of the myocardial perfusion PET imaging and myocardial metabolic PET imaging, imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

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 myocardial perfusion positron emission tomography (PET) imaging (MPI) and myocardial metabolic positron emission tomography (PET) 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

Exercise stress test study

18752-6

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

BILLING/CODING INFORMATION:

CPT Coding

78459

Myocardial imaging, positron emission tomography (PET), metabolic evaluation

78491

Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress

78492

Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress

REIMBURSEMENT INFORMATION:

PET scans are performed using a camera that has either been approved or cleared for marketing by the Food and Drug Administration (FDA) to image positron annihilation gamma photons in the body.

PET scans are performed using FDA approved or radiopharmaceutical (tracer, radiotracer) (e.g., ammonia N-13, Fluorodeoxyglucose F-18 FDG, Rubidium Rb-82). The radiopharmaceutical may be manufactured on site, or manufactured at a regional delivery center with delivery to the institution performing the PET scan. When the radiopharmaceutical is provided by an outside distribution center, there may be a separate charge for both the radiopharmaceutical and transportation of the radiopharmaceutical.

**American College of Cardiology (ACC) and American Heart Association (AHA) (2002) defines coronary artery disease risk factors/clinical predictors as:

High risk factors/Major clinical predictors

Unstable coronary syndromes, decompensated congestive heart failure (CHF), significant arrhythmias, severe valvular disease

Intermediate risk factors/Intermediate clinical predictors

Mild angina pectoris, prior myocardial infarction (MI), compensated or prior CHF, diabetes mellitus, renal insufficiency

Low risk factors/minor clinical predictors

Advanced age, abnormal electrocardiogram (ECG), rhythm other than sinus, low functional capacity, history stroke, uncontrolled systemic hypertension

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: Myocardial Imaging, Positron Emission tomography (PET) Scan, and (L29231) located at fcso.com.

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: PET (FDG) for Myocardial Viability (220.6.8) and PET for Perfusion of the Heart (220.6.1) located at cms.gov.

DEFINITIONS:

Asymptomatic: showing or causing no symptoms.

Attenuation: attenuation is the decrease in intensity of a photon signal along its path to the detector. During nuclear cardiac imaging, non-uniform attenuation occurs as photons pass through tissues of varying densities, such as the subdiaphragmatic tissues, chest wall, spine, and breasts. This results in an attenuation artifact whose extent varies with location of soft tissue, overall patient body size, and depth of target organ (heart).

Attenuation artifact: attenuation artifact leads to loss of diagnostic accuracy as artifacts may be confused with true perfusion abnormalities, resulting in an increase in false-positives.

Equivocal: of uncertain nature or classification.

Habitus: posture or position of the body. Physique; body build and constitution.

Myocardial metabolic PET imaging: the cardiac muscle is imaged using data received from positron-emitting radionuclides administered to the patient. The collision of the positrons emitted by the radionuclide with the negatively charged electrons normally present in tissue is then computer synthesized to produce an image, usually in color. This image will show the presence or absence of ischemic cardiac tissue.

Myocardial perfusion PET imaging: imaging of the cardiac muscle is performed using data received from positron-emitting radionuclides administered to the patient. Collision of the positrons emitted by the radionuclide with the negatively charged electrons normally present in tissue is then computer synthesized to produce an image, usually in color. The procedure may be performed at rest or stress.

Symptomatic: indicative (of a particular disease or disorder).

RELATED GUIDELINES:

Cardiac Radionuclide Imaging (Myocardial Perfusion Imaging, Cardiac Blood Pool Imaging) 04-78000-19
FDG-SPECT, 04-78000-15

Positron Emission Tomography (PET Scan) Oncologic Applications, 04-78000-17

Positron Emission Tomography (PET Scans) Miscellaneous Applications, 04-78000-18

OTHER:

Other names used to report positron emission tomography (PET):

Positron emission transverse tomography (PETT)
Positron emission coincident imaging (PECI)

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ-National Guideline Clearinghouse-Procedure Guideline for Myocardial Perfusion Imaging, 10/24/05.
  2. American College of Cardiology/American Heart Association Practice Guidelines-AAC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging, 2003.
  3. American Society of Nuclear Cardiology-An Overview of Nuclear Cardiology (Myocardial Perfusion Imaging, Positron-Emission tomography (PET)), 2009.
  4. Bacharach SL, Bax JJ, Case J et al. PET myocardial glucose metabolism and perfusion imaging: Part I-Guidelines for patient preparation and data acquisition. Journal of Nuclear Cardiology 2003; 10(5): 543-556.
  5. Beanlands RS, Chow BJ, Dick A et al. CCS/CAR/CANM/CNCS/Can SCMR Joint Position Statement on Advanced Non-invasive Cardiac Imaging Using Positron Emission Tomography, Magnetic Resonance Imaging and Multi-Detector Computed Tomographic Angiography in the Diagnosis and Evaluation of Ischemic Heart Disease – Executive Summary. Canadian Journal of Cardiology 2007; 23(2): 107-119.
  6. Blue Cross Blue Shield Association Medical Policy-Cardiac Applications of PET Scanning (6.01.20), 07/14/11.
  7. Brindis RG, Douglas PS, Hendel RC et al. ACC/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI)-A report of the American College of Cardiology foundation quality strategic directions committee appropriateness criteria working group and the American Society of Nuclear Cardiology. Journal of the American College of Cardiology 2005; 46(8): 1587-1605.
  8. Centers for Medicare & Medicaid Services (CMS)-NCD for PET (FDG) for Myocardial Viability (220.6.8), 01/28/05.
  9. Centers for Medicare & Medicaid Services (CMS)-NCD for PET for Perfusion of the Heart (220.6.1), 04/03/09.
  10. Des Prez RD, Shaw LJ, Gillespie RL et al. Cost-effectiveness of myocardial perfusion imaging: a summary of the currently available literature. Journal of Nuclear Cardiology 2005; 12(6): 750-9.
  11. Di Bella EV, Kadrmas DJ, Christian PE. Feasibility of dual-isotope coincidence/single-photon imaging of the myocardium. Journal of Nuclear Medicine 2001; 42(6): 944-950.
  12. Di Carli MF, Dorbala S, Meserve J et al. Clinical myocardial perfusion PET/CT. Journal of Nuclear Medicine 2007; 48(5): 783-793.
  13. Eagle KA, Berger PB, Calkins H et al. ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery-A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1996 guidelines on perioperative cardiovascular evaluation for noncardiac surgery), 2002.
  14. ECRI Institute Windows on Medical Technology-FDG SPECT for Diagnosing Ischemic Heart Disease, January 1998.
  15. FDA Talk Paper-FDA proposes Rule on Current Good Manufacturing Practices for Positron Emission Tomography (PET) Drugs, 09/15/05.
  16. First Coast Service Options, Inc. LCD for Myocardial Imaging, Positron Emission Tomography (PET) Scan, (L29231), 06/01/13.
  17. Fraker TE, Fihn SD. 2007 Chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina. Journal of the American College of Cardiology 2007; 40(23): 2264-2274.
  18. Gibbons, Balady GJ, Bricker J T et al. ACC/AHA 2002 guideline update for exercise testing. Circulation 2002; 106:1883.
  19. Greenland P, Smith SC, Grundy SM. Improving coronary heart disease risk assessment in asymptomatic people-Role of traditional risk factors and noninvasive cardiovascular tests. Circulation 2001; 104:1863-1867.
  20. Grundy SM, Pasternak R, Greenland P et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations. Circulation 1999; 100:1481-1492.
  21. Hendel RC, Budoff M J, Cardella JF et al. ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key data elements and definitions for cardiac imaging-American College of Cardiology/American Heart Association Task Force on clinical data standards. Journal of the American of Cardiology 2008; 20(10): 1-34.
  22. Hendel RC, Wackers RJ, Berman DS et al. American Society of Nuclear Cardiology consensus statement: Reporting of radionuclide myocardial perfusion imaging studies. Journal of Nuclear Cardiology 2006; 13(6): e152-6.
  23. Hesse B, Tagil K, Cuocolo A et al. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. European Journal of Nuclear Medicine and Molecular Imaging 2005; 32(7): 855-897.
  24. Klocke FJ, Baird MG, Bateman TM et al. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac Radionuclide Imaging, 2003.
  25. Machac J, Bacharach SL, Bateman TM et al. Positron emission tomography myocardial perfusion and glucose metabolism imaging. Journal of Nuclear Cardiology 2006; 13 (6): e121-e151.
  26. Medicare National Coverage Determinations, Chapter 1, Part 4-FDG PET for Myocardial Viability, 01/28/05.
  27. Merhige ME, Breen WJ Shelton V et al. Impact of myocardial imaging with PET and (82) Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management. Journal of Nuclear Cardiology 2007; 48(7): 1069-1076.
  28. National Guideline Clearinghouse-Coronary heart disease (CHD): symptoms, diagnosis and treatment, 2008.
  29. National Heart Lung and Blood Institute – Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks, 2009.
  30. National Imaging Associates, Inc. Clinical Guidelines-Heart (Cardiac) PET, 05/12.
  31. Sato H, Iwasaki T, Toyama T et al. Prediction of functional recovery after revascularization in coronary artery disease using (18) F-FDG and (123) I-BMIPP SPECT. Chest 2000; 117(1): 65-72.
  32. Schelbert HR, Beanlands R, Bengel F et al. PET myocardial perfusion and glucose metabolism imaging: Part 2-Guidelines for interpretation and reporting. Journal of Nuclear Cardiology 2003; 10(5): 557-571.
  33. Siebelink HM, Blanksma PK, Crijns HJ et al. No difference in cardiac event-free survival between positron emission tomography-guided and single-photon emission computed tomography-guided patient management: a prospective, randomized comparison of patients with suspicion of jeopardized myocardium. Journal of the American College of Cardiology 2001; 37(1): 81-88.
  34. Tarakji KG, Brunken R, McCarthy PM et al. Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction. Circulation 2006; 113: 230-237.
  35. Tilkemeier PL, Cooke CD, Ficaro EP et al. American Society of Nuclear Cardiology information statement: Standardized reporting matrix for radionuclide myocardial perfusion imaging. Journal of Nuclear Cardiology 2006; 13:e157-71.
  36. U.S. Food and Drug Administration-Part 892 Radiology Devices (Positron camera), 04/01/08.
  37. Young LH, Wackers FJ, Chyun DA et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes. The Journal of the American Medical Association 2009; 301(15): 1547-1555.
  38. Zipes DP, Camn AJ, Borggrefe M et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death-executive summary. Circulation 2006; 114; 1088-1132.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/24/12.

GUIDELINE UPDATE INFORMATION:

10/15/03

Annual review. Developed separate policy for PET Scans Cardiac Applications.

01/01/04

2004 HCPCS update: deleted Q4078 and replaced with A9526.

03/15/05

Added program exception for Health Options, Blue Care, and Medicare Advantage products.

12/15/05

Revised the when services are covered section; ICD-9-CM diagnoses codes (expand the code range for coronary atherosclerosis, revise the descriptor for: V45.09 and V45.89).

Revised reimbursement information section; revise IDC-9 diagnoses code description, deleted FDA statement regarding the camera and radiotracer. Revised program exception section; add 78459 to NIA’s general statement, and updated references. No longer scheduled for review.

03/15/06

HCPCS update, deleted G0030, G0031, G0032, G0033, G0034, G0035, G0036, G0037, G0038, G0039, G0040, G0041, G0042, G0043, G0044, G0045, G0046, G0047, and G0230.

06/15/06

Added A9552. Revised program exception; NIA statement, and updated references.

07/01/07

Reformatted guideline. Revised coverage statement for PET myocardial imaging. Revised reimbursement statement. Deleted generation of automated data (78890, 78891) reimbursement statement. Added HCPCS code A9555. Deleted HCPCS code Q3000. Added information regarding myocardial perfusion imaging and myocardial viability to section entitled “Other”, and updated references.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled reviewed. No change in position statement. Changed PET myocardial imaging to PET cardiac imaging. Added code S8085, and 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.

07/15/09

Annual review. Revised description. Revised position statements to include medically necessary indications for myocardial perfusion PET imaging and myocardial metabolic PET imaging. Deleted S8085. Added guideline specific definitions. Added program exception for Medicare Advantage products. Added related guideline link for FDG-SPECT. Updated references.

01/01/10

Revised BCBSF Radiology Management program exception section.

06/15/10

Annual review. Revised Medicare Advantage products program exception; ICD-9 code descriptor (428.20 – 428.23, 428.30 – 428.33, and 428.40 – 428.43). Updated references.

10/01/11

Revision; Formatting changes.

06/15/12

Scheduled review; deleted Medicare ICD-9 codes and updated references.

01/01/14

Review. Updated program exception and references.

04/15/17

Code update; deleted A9526, A9552 and A9555.

Date Printed: August 18, 2017: 10:14 AM