MUGA Scan - CAM 733

Description
Multiple-gated acquisition (MUGA) scanning uses radio-labelled red blood cells to scan right and left ventricular images in a cine loop format that is synchronized with the electrocardiogram.

A prior MUGA scan is not an indication for repeat MUGA (if another modality would be suitable, i.e., TTE)  

Abbreviations

EF Ejection Fraction
MUGA   

Multiple Gated Acquisition (nuclear scan of ventricular function)

TTE Transthoracic echocardiography

Policy
Multiple Gated Acquisition (MUGA) Scan is considered MEDICALLY NECESSARY for the following indications: 

GENERAL INFORMATION
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. All prior relevant imaging results, and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Indications for Multiple Gated Acquisition (MUGA) Scan
(Doherty, 2019)

  • To evaluate left ventricular function in a patient with coronary artery disease, valvular heart disease, myocardial disease, or congenital heart disease, in any of the following scenarios:
    • When ventricular function is required for management, and transthoracic echocardiography (TTE) or other imaging has proven inadequate (Patel, 2013; Yancy, 2013)
    • When there are conflicting results between other testing (i.e., Myocardial Perfusion Imaging and TTE) in the measurement of ejection fraction (EF), and the results of the MUGA will help in the management of the patient
    • Prior TTE has demonstrated systolic dysfunction (EF < 50%) and management will change based on the results of the MUGA scan
  • In the course of cardiotoxic chemotherapy when TTE images are inadequate to evaluate left ventricular systolic function (Patel, 2013; Plana, 2014; Yancy, 2013; Zamorano, 2016):
    • Previous low LV ejection fraction was < 50% and receiving potentially cardiotoxic chemotherapy
    • Prior to cardiotoxic chemotherapy, and subsequently for monitoring and follow up. The frequency of testing should be left to the discretion of the ordering physician, but generally no more often than at baseline and every 6 weeks thereafter 

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

References 

  1. Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for multimodality imaging in the assessment of cardiac structure and function in nonvalvular heart disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. JACC. 2019; 73(4):488-516.
  2. 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(25):e354-471.
  3. Friedman JD, Berman DS, Borges-Neto S, et al. First-pass radionuclide angiography. J Nucl Cardiol. 2006;13(6):e42-55.
  4. Mitra D, Basu S. Equilibrium radionuclide angiocardiography: Its usefulness in current practice and potential future applications. World J Radiol, 2012; 4(10): 421–430. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495989/
  5. Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR Appropriate utilization of cardiovascular imaging in heart failure: A joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. JACC. 2013;61(21): 2207-2231.
  6. Plana JC, Galderisi M, Bara, A, et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: A report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2014;27:911-39.
  7. Ritchie JL, Bateman TM, Bonow RO, et al. Guidelines for clinical use of cardiac radionuclide imaging, report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Radionuclide Imaging) developed in collaboration with the American Society of Nuclear Cardiology. JACC. 1995;25(2):521-547.
  8. Yancy C, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. JACC. 2013;62(16):e147-237.
  9. Zamorano JL, Lancellotti P, Munoz DR, et al. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). European Heart Journal. 2016;37:2768–2801.  

Coding Section 

Code Number Description
CPT 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
  78478 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)

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2019 Forward     

11/01/2021 

Annual review, adding coverage statement related to previous low LV function and cardiotoxic chemotherapy. 

11/03/2020 

Annual review, updating policy and description for clarity. No change to policy intent. 

11/21/2019

New Policy

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