|
Medical Policy: 06.01.11
Original Effective Date: June 2004
Reviewed: July 2011
Revised: July 2011
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Cardiac positron emission tomography (PET) is a noninvasive imaging technique used to assess myocardial perfusion, left ventricular function, and viability by reflecting the distribution of radiotracers injected into the body. The most frequently used radiotracers include fluorine-18 fluorodeoxyglucose (FDG), rubidium-82 (Rb-82), and nitrogen-13 ammonia (N-13).
 Top
Prior Approval:
Not applicable
Top
Policy:
Cardiac PET scanning may be considered medically necessary for the following indications:
- To assess myocardial perfusion and thus diagnose coronary artery disease
- To assess the myocardial viability in patients with severe left ventricular dysfunction to assist in determining candidacy for revascularization.
- For the diagnosis of cardiac sarcoidosis in patients who are unable to undergo magnetic resonance imaging (MRI) scanning.
Cardiac applications of PET scanning, other than those listed above, are considered not medically necessary.
Top
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD- 9 CM diagnostic codes.
- CPT 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress.
- CPT 78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress.
- CPT 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation.
- HCPCS A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries
- HCPCS A9552 Fluorodeoxyglucose F-18 FDC, diagnostic, per study dose, up to 45 millicuries
- HCPCS A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries
- HCPCS S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (nondedicated PET scan)
Top
Selected References:
- Udelson JE, Beshansky JR, Ballin DS, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002 Dec 4; 288(21):2693-700.
- Gerber BL, Ordoubadi FF, Wijns W, et al. Positron emission tomography using (18)F-fluoro-deoxyglucose and euglycaemic hyperinsulinaemic glucose clamp: optimal criteria for the prediction of recovery of post-ischaemic left ventricular dysfunction. Eur Heart J. 2001 Sep;22(18):1691-701.
- Garber AM, Soloman NA. Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease. Ann Intern Med. 1999 May 4;130(9):719-28.
- Siebelink HM, Blanksma PK, Crijns HJ. 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. J Am Coll Cardiol. 2001 Jan;37(1):81-8.
- Klocke FJ, Baird MG, Bateman TM et al. ACC/AHA/ASNC guidelines for clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/American Heart Association task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Radionuclide Imaging). 2003 American College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/radio/rni_fulltest.pdf
- Machac J, Bacharach SL, Bateman TM et al. Positron emission tomography myocardial perfusion and glucose metabolism imaging. J Nucl Cardiol 2006;13:e121-51.
- Sharma S. Cardiac imaging in myocardial sarcoidosis and other cardiomyopathies. Curr Opin Pulm Med 2009; 15(5):507-12.
Top
Policy History:
Date Reason Action
July 2011 Annual review Revised
Top
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
|
 |
