Myocardial Perfusion Imaging (Nuc Card) - CAM 747

Description
This guideline is for stress imaging, specifically myocardial perfusion imaging (MPI), with appropriate preference for alternatives, such as stress echocardiography (SE) or stress ECG alone when more suitable (see section below).

Radionuclide myocardial perfusion imaging (MPI) allows for evaluation of cardiac perfusion at rest and at exercise, as well as using pharmacologic agents for the diagnosis and management of coronary artery disease. With radionuclide MPI, pharmacologic stress may be performed with an inotropic agent or vasodilator.  These agents are indicated for patients who cannot reach an adequate endpoint with physical exercise stress testing.

Stable patients without known CAD fall into 2 categories:

  • Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Websites for Global Cardiovascular Risk Calculators section).
  • Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant (> 70%) CAD (below):

The 3 Types of Chest Pain or Discomfort

  • Typical Angina (Definite) is defined as including all 3 characteristics:
    • Substernal chest pain or discomfort with characteristic quality and duration
    • Provoked by exertion or emotional stress
    • Relieved by rest and/or nitroglycerine
  • Atypical Angina (Probable) has only 2 of the above characteristics
  • Nonanginal Chest Pain/Discomfort has only 0 - 1 of the above characteristics

Once the type of chest pain has been established from the medical record, the Pretest Probability of obstructive CAD is estimated from the Diamond Forrester Table below, recognizing that in some cases multiple additional coronary risk factors could increase pretest probability:

Age (Years)

Gender

Typical/Definite Angina Pectoris

Atypical/Probable Angina Pectoris

Nonanginal Chest Pain

≤ 39

 

Men

Intermediate

Intermediate

Low

Women 

Intermediate 

Very low

Intermediate

40–49

 

Men

High

Intermediate

Intermediate

Women

Intermediate

Intermediate

Very low

50–59

 

Men

High

Intermediate

Intermediate

Women

Intermediate

Intermediate

Low

≥ 60

 

Men

High

Intermediate

Intermediate

Women

High 

Intermediate 

Intermediate 

  • Very low: < 5% pretest probability of CAD, usually not requiring stress evaluation
  • Low: 5 - 10% pretest probability of CAD
  • Intermediate: 10% - 90% pretest probability of CAD
  • High: > 90% pretest probability of CAD

OVERVIEW:
MPI may be performed without diversion to SE in any of the following (see below):

Inability to Exercise

  • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
  • Limited functional capacity (< 4 METS) such as one of the following:
    • Unable to take care of their ADLs or ambulate
    • Unable to walk 2 blocks on level ground
    • Unable to climb 1 flight of stairs

Other Comorbidities

  • Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
  • Poorly controlled hypertension, with systolic BP > 180 or diastolic BP > 120 (and clinical urgency not to delay MPI)

ECG and Echo Related Baseline Findings

  • Prior cardiac surgery (coronary artery bypass graft or valvular)
  • Obesity with body mass index (BMI) over 40 kg/m2 or documented poor acoustic imaging window
  • Left ventricular ejection fraction ≤ 40%
  • Pacemaker or ICD
  • Persistent Atrial fibrillation
  • Resting wall motion abnormalities that would make SE interpretation difficult
  • Complete left bundle branch block (LBBB)

Risk Related scenarios

  • High pretest probability of suspected CAD
  • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs (prior to initiation of therapy)
  • Arrhythmia risk with exercise

ECG Stress Test Alone versus Stress Testing with Imaging

Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise:

  • The (symptomatic) low or intermediate pretest probability patient who is able to exercise and has an interpretable ECG
  • The patient who is under evaluation for exercise induced arrhythmia
  • The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
  • For the evaluation of syncope or presyncope during exertion

Duke Exercise ECG Treadmill Score

Ccalculates risk from ECG treadmill alone:

  • The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x 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

An uninterpretable baseline ECG includes:

  • ST segment depression 1 mm or more; (not for non-specific ST- T wave changes)
  • Ischemic looking T waves; at least 2.5 mm inversions (excluding V1 and V2)
  • LVH with repolarization abnormalities, pre-excitation pattern such as WPW, ventricular paced rhythm, or LBBB
  • Digitalis use with associated ST segment abnormalities

Global Risk of Cardiovascular Disease

Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years. High global risk by itself generally lacks scientific support as an indication for stress imaging. There are rare execeptions, such as patients requiring IC antiarrhythmic drugs, who might require coronary risk stratification prior to initiation of the drug or patients with a CAC score > 400 Agatston units, when global risk is moderate or high.

  • CAD Risk — Low: 10-year absolute coronary or cardiovascular risk less than 10%.
  • CAD Risk — Moderate: 10-year absolute coronary or cardiovascular risk between 10% and 20%.  
  • CAD Risk — High: 10-year absolute coronary or cardiovascular risk of greater than 20%.  

Websites for Global Cardiovascular Risk Calculators*

(*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.)

Risk Calculator

Websites for Online Calculator

Framingham Cardiovascular Risk

https://reference.medscape.com/calculator/framingham-cardiovascular-disease-risk

Reynolds Risk Score
Can use if no diabetes
Unique for use of family history

http://www.reynoldsriskscore.org/

Pooled Cohort Equation

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

ACC/AHA Risk Calculator

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

MESA Risk Calculator
With addition of Coronary Artery Calcium Score, for CAD-only risk

https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx

Definitions of Coronary Artery Disease

Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).

  • Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. It is not a diagnostic tool so much as it is a risk stratification tool. Its incorporation into global risk can be achieved by using the MESA risk calculator.
  • Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
    • Suggested by percentage diameter stenosis ≥ 70% by angiography; borderline lesions are 40 - 70%
    • For a left main artery, suggested by a percentage stenosis ≥ 50% or minimum lumen cross sectional area on IVUS ≤ 6 square mm 
    • FFR (fractional flow reserve) ≤ 0.80 for a major vessel
    • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
  • FFR (fractional flow reserve) is the distal to proximal pressure ratio across a coronary lesion. Less than or equal to 0.80 is considered a significant reduction in coronary flow.

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. This may include 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 per se is not an anginal equivalent.

Abbreviations

ADLs Activities of daily living
BSA

Body surface area in square meters

CAD Coronary artery disease

ECG

Electrocardiogram

FFR

Fractional flow reserve

LBBB

Left bundle-branch block

LVEF

Left ventricular ejection fraction

LVH

Left ventricular hypertrophy

MI

Myocardial infarction

MET

Estimated metabolic equivalent of exercise

MPI

Myocardial perfusion imaging

PFT

Pulmonary function test

PVCs

Premature ventricular contractions
SE Stress echocardiography
VT Ventricular tachycardia

VF

Ventricular fibrillation
WPW Wolf Parkinson White

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.

Policy
Myocardial Perfusion Imaging is considered MEDICALLY NECESSARY for the following indications: 

Symptomatic patients without known CAD (Use Diamond Forrester table)

  • Low pretest probability and unable to exercise (SE diversion not required)
  • Intermediate pre-test probability with an uninterpretable ECG or unable to exercise 
  • High pretest probability (Stress Echocardiogram SE diversion not required) 
  • Repeat testing in a patient with new or worsening symptoms and negative result at least one year prior AND meets one of the criteria above

Asymptomatic patients without known CAD (SE diversion not required)

  • Previously unevaluated ECG evidence of possible myocardial ischemia including substantial ischemic ST segment or T wave abnormalities (See Overview section)
  • Previously unevaluated pathologic Q waves
  • Previously unevaluated complete left bundle branch block

INCONCLUSIVE CAD EVALUATION WITHIN THE PAST 2 YEARS AND OBSTRUCTIVE CAD REMAINS A CONCERN

  • Exercise stress ECG with low risk Duke treadmill score (≥5), (see Overview) but patient’s current symptoms indicate an intermediate or high pretest probability (SE diversion not required for high pretest probability)
  • Exercise stress ECG with an intermediate Duke treadmill score
  • Intermediate coronary computed tomography angiography (CCTA) (e.g., 30 - 70% lesions)
  • Non-diagnostic exercise stress test with inability to achieve target heart rate (THR)
  • An indeterminate (equivocal, borderline, or discordant) evaluation by prior stress imaging (SE or CMR) within the past 2 years 

FOLLOW-UP OF PATENTS POST CORONARY REVASCULARIZATION (PCI or CABG)

  • Asymptomatic follow-up stress imaging (MPI or SE) at a minimum of 2 years post coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI), (whichever is later), is appropriate only for patients with a history of silent ischemia, or a history of a prior left main stent.

OR

For patients 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)

  • New, recurrent, or worsening symptoms post coronary revascularization, is an indication for stress imaging (MPI or SE), if it will alter management  

FOLLOW-UP OF KNOWN CAD

Follow-up of asymptomatic or stable symptoms when last invasive or non-invasive assessment of coronary disease showed hemodynamically significant CAD (ischemia on stress test or FFR ≤ 0.80 or stenosis ≥ 70% of a major vessel), over two years ago, without intervening coronary revascularization is an appropriate indication for stress imaging (MPI or SE) in patients if it will alter management  

SPECIAL DIAGNOSTIC CONDITIONS REQUIRING CORONARY EVALUATION 

  • Prior acute coronary syndrome (with documentation in MD notes), without invasive or non-invasive coronary evaluation (SE diversion not required)
    • Newly diagnosed systolic heart failure (EF < 50%) with symptoms or signs of ischemia unless invasive coronary angiography is immediately planned
    • LVEF ≤ 50% requiring myocardial viability assessment to assist with decisions regarding coronary revascularization (SE diversion not required) 
    • Ventricular arrhythmias (Propafenone or Flecanide), in intermediate and high global risk patients (SE diversion not required)
      • Sustained ventricular tachycardia (VT) > 100 bpm, ventricular fibrillation (VF), or exercise induced VT, when invasive coronary arteriography is not immediately planned (SE diversion not required)
      • Nonsustained VT, multiple episodes, each ≥ 3 beats at ≥ 100 bpm, or frequent PVCs (defined as greater than or equal to 30/hour on remote monitoring) without known cause or associated cardiac pathology, when an exercise ECG cannot be performed
    • Prior to Class IC antiarrhythmic drug initiation
    • Assessment of hemodynamic significance of one of the following documented conditions:
      • Anomalous coronary arteries
      • Myocardial bridging of coronary artery (perform with exercise stress)
  • Coronary aneurysms in Kawasaki’s disease or due to atherosclerosis
  • Following radiation therapy to the anterior or left chest, at 5 years post initiation and every 5 years thereafter

PRIOR TO ELECTIVE NON-CARDIAC SURGERY

  • Patients who have no above indication for non-invasive coronary evaluation, but are referred for preoperative cardiac evaluation, are eligible for MPI if all 4 criteria are met:
    • Surgery is supra-inguinal vascular, intrathoracic, or intra-abdominal; AND
    • The patient has at least one of the additional cardiac complication risk factors:
      • Ischemic Heart Disease
      • History of stroke or transient ischemic attack (TIA)
      • History of congestive heart failure or ejection fraction ≤ 35% 
      • Insulin-requiring diabetes mellitus
      • Creatinine ≥ 2.0 mg/dl

AND

  • The patient has limited functional capacity (< 4 METS), such as one of the following:
    • Unable to take care of their activities of daily living (ADLs) or ambulate
    • Unable to walk 2 blocks on level ground
    • Unable to climb 1 flight of stairs

AND

  • There has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year; and the results of such a test would be likely to substantially alter therapy and/or preclude proceeding with the intended surgery.
  • Planning for solid organ transplantation is an indication for preoperative MPI, if there has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year andwith ≥ 3 of the following risk factors: (SE diversion not required):
    • Age > 60
    • Smoking
    • Hypertension
    • Dyslipidemia
    • Left ventricular hypertrophy
    • > 1 year on dialysis (for renal transplant patients)
    • Diabetes mellitus
    • Prior ischemic heart disease

POST CARDIAC TRANSPLANT (SE diversion not required)

Annually, for the first five years post cardiac transplantation, in a patient not undergoing invasive coronary arteriography

  • After the first five years post cardiac transplantation, patients with documented transplant coronary vasculopathy can be screened annually if the risk of annual invasive coronary arteriography is not acceptable (e.g. high risk of contrast nephropathy) or not planned

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

References  

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Coding Section 

Code Number Description
CPT 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 imaging, infarct avid, planar; 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
  78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine

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 and 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     

12/08/2021 

Annual review, no change to policy intent. 

11/03/2020 

Annual review, no change to policy intent. Updating verbiage for clarity, also updating description and references. 

12/03/2019

New Policy

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