Practice Estimate of Effective Radiation Dose chart for Selected Imaging Studies

Imaging Study	Estimate of Effective Radiation Dose
Sestamibi myocardial perfusion study (MPI) PET myocardial perfusion study: Rubidium-82 NH3	9-12 mSv 3 mSv 2 mSv
Thallium myocardial perfusion study (MPI)	22-31 mSv
Diagnostic conventional coronary angiogram (cath)	5-10 mSv
Computed tomography coronary angiography (CTCA) (with prospective gating)	5-15 mSv Less than 5 mSv
CT of Abdomen and pelvis	8-14 mSv
Chest x-ray	<0.1 mSv

CD-1.1: General Issues – Cardiac

For this condition imaging is medically necessary based on the following criteria:

† Cardiac imaging is not indicated if the results will not affect member management decisions. If a decision to perform cardiac catheterization or other angiography has already been made, there is often no need for imaging stress testing.

† A current clinical evaluation (within 60 days) is required prior to considering advanced imaging, which includes:

® Relevant history and physical examination and appropriate laboratory studies and non-advanced imaging modalities, such as recent ECG (within 60 days), chest x-ray or ECHO/ultrasound, after symptoms started or worsened.
¡ Effort should be made to obtain copies of reported “abnormal” ECG studies in order to determine whether the ECG is uninterpretable for ischemia on ETT
¡ Most recent previous stress testing and its findings should be obtained
¡ Other meaningful contact (telephone call, electronic mail or messaging) by an established member can substitute for a face-to-face clinical evaluation.
® Vital signs, height, and weight or BMI or description of general habitus is needed.
® Advanced imaging should answer a clinical question which will affect management of the member’s clinical condition.
® Assessment of ischemic symptoms can be determined by the following:
¡ Typical angina (definite):
§ Angina pectoris is classified as typical when all of the following are present:
— Substernal chest discomfort (generally described as pressure, heaviness, burning, or tightness)
— Brought on by exertion or emotional stress
— Relieved by rest or nitroglycerin
§ May radiate to the left arm or jaw
§ When clinical information is received indicating that a member is experiencing chest pain that is "exertional" or "due to emotional stress" and relieved with rest, this meets the typical angina definition under the Pre-Test Probability Grid. No further description of the chest pain is required (location within the chest is not required).
§ The Pre-Test Probability Grid (Table 1) is based on age, gender, and symptoms. All factors must be considered in order to approve for stress testing with imaging using the Pre-Test Probability Grid.
¡ Atypical angina (probable): Chest pain or discomfort (arm or jaw pain) that lacks one of the characteristics of definite or typical angina.
¡ Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.
¡ Anginal equivalents: symptoms consistent with member’s known angina pattern in an individual with a history of CABG or PCI.

Pre-Test Probability of CAD by Age, Gender, and Symptoms
Age (years)	Gender	Typical / Definite Angina Pectoris	Atypical / Probable Angina Pectoris	Non-anginal Chest Pain	Asymptomatic
39 and younger	Men	Intermediate	Intermediate	Low	Very low
	Women	Intermediate	Very low	Very low	Very low
40 - 49	Men	High	Intermediate	Intermediate	Low
	Women	Intermediate	Low	Very low	Very low
50 - 59	Men	High	Intermediate	Intermediate	Low
	Women	Intermediate	Intermediate	Low	Very low
60 and over	Men	High	Intermediate	Intermediate	Low
	Women	High	Intermediate	Intermediate	Low
High	Greater than 90% pre-test probability
Intermediate	Between 10% and 90% pre-test probability
Low	Between 5% and 10% pre-test probability
Very Low	Less than 5% pre-test probability

For this condition imaging is medically necessary based on the following criteria:

The Exercise Treadmill Test (ETT) is without imaging.

† Necessary components of an ETT include:

® ECG that can be interpreted for ischemia.
® Member capable of exercise on a treadmill or similar device (generally at 4 METs or greater; see functional capacity below).

® ST segment depression (usually described as horizontal or downsloping, greater or equal to 1.0 mm below baseline)
® Development of chest pain
® Significant arrhythmia (especially ventricular arrhythmia)
® Hypotension during exercise

® Can walk four blocks without stopping
® Can walk up a hill
® Can climb one flight of stairs without stopping
® Can perform heavy work around the house

An observational study found that, compared with the Duke Activity Status Index, subjective assessment by clinicians generally underestimated exercise capacity see reference 25.

CD-1.3: Stress Testing with Imaging – Procedures

For this condition imaging is medically necessary based on the following criteria:

† Imaging Stress Tests include any one of the following:

® Stress Echocardiography see CD-2.6: Stress Echocardiography (Stress Echo) – Coding
® MPI see CD-3.1: Myocardial Perfusion Imaging (MPI) – Coding
® Stress perfusion MRI see CD-5.3: Cardiac MRI – Indications for Stress MRI

CD-1.4: Stress Testing with Imaging – Indications

For this condition imaging is medically necessary based on the following criteria:

† Stress echo, MPI or stress MRI, can be considered if there are new, recurrent, or worsening cardiac symptoms and any of the following:

® High pretest probability (greater than 90% probability of CAD) per Table 1
® A history of CAD based on:
¡ A prior anatomic evaluation of the coronaries OR
¡ A history of CABG or PCI
® Evidence or high suspicion of ventricular tachycardia
® Age 40 years or greater and known diabetes mellitus
® Coronary calcium score ≥ 100
® Poorly controlled hypertension defined as systolic BP greater than or equal to 180mmhg, if provider feels strongly that CAD needs evaluation prior to BP being controlled.
® ECG is uninterpretable for ischemia due to any one of the following:
¡ Complete Left Bundle Branch Block (bifasicular block involving right bundle branch and left anterior hemiblock does not render ECG uninterpretable for ischemia)
¡ Ventricular paced rhythm
¡ Pre-excitation pattern such as Wolff-Parkinson-White
¡ Greater or equal to 1.0 mm ST segment depression (NOT nonspecific ST/T wave changes)
¡ LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria)
¡ T wave inversion in the inferior and/or lateral leads. This includes leads II, AVF, V5 or V6. (T wave inversion isolated in lead III or T wave inversion in lead V1 and V2 are not included).
¡ Member on digitalis preparation
® Continuing symptoms in a member who had a normal or submaximal exercise treadmill test and there is suspicion of a false negative result.
® Members with recent equivocal, borderline, or abnormal stress testing where ischemia remains a concern, regardless of symptoms.
® Heart rate less than 50 bpm in members, including those on beta blocker, calcium channel blocker, or amiodarone, where it is felt that the member may not achieve an adequate workload for a diagnostic exercise study.
® Inadequate ETT:
¡ Physical inability to achieve target heart rate (85% MPHR or 220-age. Target heart rate is calculated as 85% of the maximum age predicted heart rate (MPHR). MPHR is estimated as 220 minus the member's age.
¡ History of false positive exercise treadmill test: a false positive ETT is one that is abnormal however the abnormality does not appear to be due to macrovascular CAD.

® Within 3 months of an acute coronary syndrome (e.g. ST segment elevation MI [STEMI], unstable angina, non-ST segment elevation MI [NSTEMI]), one MPI can be performed to evaluate for inducible ischemia if all of the following related to the most recent acute coronary event apply:
¡ Individual is hemodynamically stable
¡ No recurrent chest pain symptoms and no signs of heart failure
¡ No prior coronary angiography or imaging stress test since the current episode of symptoms
® Assessing myocardial viability in members with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered.
¡ Note: MRI, cardiac PET, MPI, or Dobutamine stress echo can be used to assess myocardial viability depending on physician preference.
¡ PET and MPI perfusion studies are usually accompanied by PET metabolic examinations (CPT^® 78459). Tl-201 MPI perfusion studies may assess viability without accompanying PET metabolism information.
® Unheralded syncope (not near syncope)
® Asymptomatic member with an uninterpretable ECG that:
¡ Has never been evaluated or
¡ Is a new uninterpretable change.
® Member with an elevated cardiac troponin.
® One routine study 2 years or more after a stent
¡ Except with a left main stent where it can be done at 1 year.
® One routine study at 5 years or more after CABG, without cardiac symptoms.
® Every 2 years if there was documentation of previous “silent ischemia” on the imaging portion of a stress test but not on the ECG portion.
® To assess for CAD prior to starting a Class IC antiarrhythmic agent (flecainide or propafenone) and annually while taking the medication.
® Prior anatomic imaging study (coronary angiogram or CCTA) demonstrating coronary stenosis in a major coronary branch, which is of uncertain functional significance, can have one stress test with imaging.

CD-1.5: Stress Testing with Imaging – Preoperative

For this condition imaging is medically necessary based on the following criteria:

† There are 2 steps that determine the need for imaging stress testing in (stable) pre-operative members:

® Would the member qualify for imaging stress testing independent of planned surgery?
¡ If yes, proceed to stress testing guidelines;
¡ If no, go to step 2
® Is the surgery considered high, moderate or low risk? (see Table 2) If high or moderate-risk, proceed below. If low-risk, there is no evidence to determine a need for preoperative cardiac testing.
¡ High Risk Surgery: All members in this category should receive an imaging stress test if there has not been an imaging stress test within 1 year* unless the member has developed new cardiac symptoms or a new change in the EKG since the last stress test.
¡ Intermediate Surgery: One or more risk factors and unable to perform an ETT per guidelines if there has not been an imaging stress test within 1 year* unless the member has developed new cardiac symptoms or a new change in the EKG since the last stress test.
¡ Low Risk: Preoperative imaging stress testing is not supported.
® Clinical Risk Factors (for cardiac death & non-fatal MI at time of non-cardiac surgery)
¡ Planned high-risk surgery (open surgery on the aorta or open peripheral vascular surgery)
¡ History of ischemic heart disease (previous MI, previous positive stress test, use of nitroglycerin, typical angina, ECG Q waves, previous PCI or CABG)
¡ History of compensated previous congestive heart failure (history of heart failure, previous pulmonary edema, third heart sound, bilateral rales, chest x-ray showing heart failure)
¡ History of previous TIA or stroke
¡ Diabetes Mellitus
¡ Creatinine level > 2 mg/dL

Table 2

Cardiac Risk Stratification List
High Risk (> 5%)	Intermediate Risk (1-5%)	Low Risk (<1%)
† Open aortic and other major open vascular surgery † Open peripheral vascular surgery	† Open intraperitoneal and/or intrathoracic surgery † Open carotid endarterectomy † Head and neck surgery † Open orthopedic surgery † Open prostate surgery	† Endoscopic procedures † Superficial procedures † Cataract surgery † Breast surgery † Ambulatory surgery † Laparoscopic and endovascular procedures that are unlikely to require further extensive surgical intervention

CD-1.6: Transplant Patients

For this condition imaging is medically necessary based on the following criteria:

† Stress Testing in members for Non-Cardiac Transplant

® Individuals who are candidates for any type of organ, bone marrow, or stem cell transplant can undergo imaging stress testing every year (usually stress echo or MPI) prior to transplant.
® Individuals who have undergone organ transplant are at increased risk for ischemic heart disease secondary to their medication. Risk of vasculopathy is 7% at one year, 32% at five years and 53% at ten years. An imaging stress test can be repeated annually after transplant for at least two years or within one year of a prior cardiac imaging study if there is evidence of progressive vasculopathy.
® After two consecutive normal imaging stress tests, repeated testing is not supported more often than every other year without evidence for progressive vasculopathy or new symptoms.
® Stress testing after five years may proceed according to normal patterns of consideration.

® One of the following imaging studies may be performed annually:
¡ MPI
¡ Stress ECHO
¡ Stress MRI
¡ Cardiac PET perfusion (CPT^® 78491 or CPT^® 78492)

For this condition imaging is medically necessary based on the following criteria:

† Procedures reported with CPT^® 78414 and CPT^® 78428 are essentially obsolete and should not be performed in lieu of other preferred modalities.

† Echocardiogram is the preferred method for cardiac shunt detection, rather than the cardiac shunt imaging study described by CPT^® 78428.

† Ejection fraction can be obtained by echocardiogram, MPI, MUGA study, cardiac MRI, cardiac CT, or cardiac PET depending on the clinical situation, rather than by the non-imaging heart function study described by CPT^® 78414.

CD-1.8: Genetic lab testing in the evaluation of CAD

For this condition imaging is medically necessary based on the following criteria:

† Corus^® CAD genetic expression score – refer to lab management program guidelines

CD-1.9: CAD Risk factor modification

For this condition imaging is medically necessary based on the following criteria:

† Risk factor modification

® Statins remain the mainstay of medical treatment for cardiovascular risk reduction with an abundance of scientific evidence regarding their efficacy.
® PCSK9 drugs are a new addition to the treatment of hyperlipidemia
¡ Refer to specialty drug coverage criteria for these drugs.

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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: Executive Summary. Circulation. 2012;126(25):3097-3137. doi:10.1161/cir.0b013e3182776f83..
3. Qaseem A, Fihn SD, Williams S, et al A. Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Annals of Internal Medicine. 2012;157(10):729. doi:10.7326/0003-4819-157-10-201211200-00010.
4. Rybicki FJ, Udelson JE, Peacock WF, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain. Journal of the American College of Cardiology. 2016;67(7):853-879. doi:10.1016/j.jacc.2015.09.011.
5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Journal of the American College of Cardiology. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944.
6. Friedewald VE, King SB, Pepine CJ, Vetrovec GW, Roberts WC. The Editor’s Roundtable: Chronic Stable Angina Pectoris. The American Journal of Cardiology. 2007;100(11):1635-1643. doi:10.1016/j.amjcard.2007.09.001.
7. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 Guideline Update for Exercise Testing Summary Article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardio 2002; 40:531-1540. doi:10.1161/01.CIR.0000034670.06526.15.
8. Ho PM, Rumsfeld JS, Peterson PN. Chest pain on exercise treadmill test predicts future cardiac hospitalizations. Clin Cardiol 2007; 30:505-510. doi:10.1002/clc.20139.
9. Lauer MS, Pothier CE, Magid DJ, et al. An externally validated model for predicting long-term survival after exercise treadmill testing in patients with suspected coronary artery disease and a normal electrocardiogram. Ann Intern Med 2007; 147:821-828. doi:10.7326/0003-4819-147-12-200712180-00001.
10. Marshall AJ, Hutchings F, James AJ, et al. Prognostic value of a nine minute treadmill test in patients undergoing myocardial perfusion scintigraphy. Am J Cardiol 2010 Nov: 106(10):1423-1428. doi:10.1016/j.amjcard.2010.06.074.
11. Mieres JH and Blumenthal RS. Does the treadmill test work in women? Cardiosource Spotlight, 2008 Jul 1; CS2-CS4. https://www.medscape.com/viewarticle/578141_3.
12. Peterson PN, Magid DJ, Ross C, et al. Association of exercise capacity on treadmill with future cardiac events in patients referred for exercise testing. Arch Intern Med 2008; 168(2):174-179. doi:10.1001/archinternmed.2007.68.
13. Picano E, Pasanisi E, Brown J, et al. A gatekeeper for the gatekeeper: Inappropriate referrals to stress echocardiography. Am Heart J 2007; 154: 285-290. doi:10.1016/j.ahj.2007.04.032.
14. Poirier P, Alpert MA, Fleisher LA, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009; 120:86-95. doi:10.1161/CIRCULATIONAHA.109.192575.
15. Sechtem U. Do heart transplant recipients need annual coronary angiography? European Heart Journal 2001; 22:895–897. doi:10.1053/euhj.2001.2660.
16. Southard J, Baker L, Schaefer S. In search of the false-negative exercise treadmill testing evidence-based use of exercise echocardiography. Clin Cardiol 2008; 31:35-40.doi:10.1002/clc.20174/abstract.
17. Tavel ME. Stress testing in cardiac evaluation: Current concepts with emphasis on the ECG. Chest 2001; 119:907-925. doi:10.1378/chest.119.3.907.
18. Taylor DO, Edwards LB, Boucek MM, et al. Registry of the International Society for Heart and Lung Transplantation: Twenty-fourth official adult heart transplant report—2007. J Heart Lung Transplant 2007 August; 26(8):769-781. doi:10.1016/j.healun.2007.06.004.
19. Diamond GA. A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1983; 1:574–5. doi:10.1016/S0735-1097(83)80093-X.
20. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS. 2013 Multi-modality 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. J Am Coll Cardiol 2014; 63: forthcoming. doi:10.1016/j.jacc.2013.11.009.
21. Blank P, Scheopf UJ, Leipsic JA. CT in transcatheter aortic valve replacement. Radiology, 2013; 269(3). doi:10.1148/radiol.13120696.
22. Leipsic JA, Blanke P, Hanley M, et al. ACR Appropriateness Criteria ^® Imaging for Transcatheter Aortic Valve Replacement. Journal of the American College of Radiology. 2017;14(11). doi:10.1016/j.jacr.2017.08.046.
23. Mieres JH, Gulati M, Bairey Merz N, et al. American Heart Association Cardiac Imaging Committee of the Council on Clinical Cardiology, Cardiovascular Imaging and Intervention Committee of the Council on Cardiovascular Radiology. Role of Noninvasive Testing in the Clinical Evaluation of Women with Suspected Ischemic Heart Disease A Consensus Statement From the American Heart Association Circulation. 2014; 130(4):350. doi:10.1161/CIR.0000000000000061.
24. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011; 57:1126. doi:10.1016/j.echo.2010.12.008.
25. Melon CC, Eshtiaghi P, Luksun WJ, et al. Validated questionnaire vs physicians' judgment to estimate preoperative exercise capacity. JAMA Intern Med 2014; 174:1507. doi:10.1001/jamainternmed.2014.2914.
26. Taqueti V, Dorbala S, Wolinsky D. Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease— state-of-the-evidence and clinical recommendations. Journal of Nuclear Cardiology. June 2017. doi.org/10.1007/s12350-017-0926-8.
27. Chamberlain JJ, Johnson EL, Leal S, et al. Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Annals of Internal Medicine. 2018;168(9):640. doi:10.7326/m18-0222.
28. Bateman TM, Dilsizian V, Beanlands RS, Depuey EG, Heller GV, Wolinsky DA. American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging Joint Position Statement on the Clinical Indications for Myocardial Perfusion PET. Journal of Nuclear Medicine. 2016;57(10):1654-1656. doi:10.2967/jnumed.116.180448



CD-2: Echocardiography (ECHO)

CD-2.1: Transthoracic Echocardiography (TTE) – Coding

CD-2.2: Transthoracic Echocardiography (TTE) – Indications

CD-2.3: Frequency of Echocardiography Testing

CD-2.4: Transesophageal Echocardiography (TEE) – Coding

CD-2.5: Transesophageal Echocardiography (TEE) – Indications

CD-2.6: Stress Echocardiography (Stress Echo) – Coding

CD-2.7: Stress Echocardiography–Indications, other than ruling out CAD

CD-2.8: 3D Echocardiography – Coding

CD-2.9: 3D Echocardiography – Indications

CD-2.10: Myocardial strain imaging

CD-2.11: Myocardial contrast perfusion echocardiography

CD-2.1: Transthoracic Echocardiography (TTE) – Coding

For this condition imaging is medically necessary based on the following criteria:

TTE CODES
Transthoracic Echocardiography		CPT®
TTE for congenital cardiac anomalies, complete		93303
TTE for congenital cardiac anomalies, follow-up or limited		93304
TTE with 2-D, M-mode, Doppler and color flow, complete		93306
TTE with 2-D, M-mode, without Doppler or color flow		93307
TTE with 2-D, M-mode, follow-up or limited		93308
Doppler Echocardiography		CPT®
Doppler echo, pulsed wave and/or spectral display		+93320*
Doppler echo, pulsed wave and/or spectral display, follow-up or limited study		+93321*
Doppler echo, color flow velocity mapping		+93325
*CPT® 93320 and CPT® 93321 should not be requested or billed together
Transthoracic Echocardiography		CPT®
C8921	TTE for congenital cardiac anomalies, complete	93303
C8922	TTE for congenital cardiac anomalies, follow-up or limited	93304
C8929	TTE with 2-D, M-mode, Doppler and color flow, complete	93306
C8923	TTE with 2-D, M-mode, without Doppler or color flow	93307
C8924	TTE with 2-D, M-mode, follow-up or limited	93308
C codes are unique temporary codes established by CMS. C codes were established for contrast echocardiography. Each echocardiography C code corresponds to a standard echo code (Class I CPT code) The C code and the matching CPT code should not both be approved.
Myocardial strain imaging
Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (List separately in addition to codes for echocardiography imaging)		93356
Investigational Codes
0439T	Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability	Investigational

CD-2.1.1: Transthoracic Echocardiography (TTE) – Coding - General Information

† The most commonly performed study is a complete transthoracic echocardiogram with spectral and color flow Doppler (CPT^® 93306).

® CPT^® 93306 includes the Doppler exams, so CPT^® codes 93320-93325 should not be assigned together with CPT^® 93306.
® Doppler codes (CPT^® 93320, CPT^® 93321, and CPT^® 93325) are ‘add-on codes’ (as denoted by the + sign) and are assigned in addition to code for the primary procedure.

† Limited transthoracic echocardiogram should be billed if the report does not “evaluate or document the attempt to evaluate” all of the required structures.

® A limited transthoracic echocardiogram is reported with CPT^® 93308.
® CPT^® 93321 (not CPT^® 93320) should be reported with CPT^® 93308 if Doppler is included in the study. CPT^® 93325 can be reported with CPT^® 93308 if color flow Doppler is included in the study.
® A limited congenital transthoracic echocardiogram is reported with CPT^® 93304.

® Shortness of breath
® Known or suspected valvular disease
® Known or suspected hypertrophic obstructive cardiomyopathy
® Shunt detection

† Providers performing echo on a pediatric member, may not know what procedure codes they will be reporting until the initial study is completed.

† If a congenital issue is found on the initial echo, a complete echo is reported with codes CPT^® 93303, CPT^® 93320, and CPT^® 93325 because CPT^® 93303 does NOT include Doppler and color flow mapping.

† If no congenital issue is discovered, then CPT^® 93306 is reported alone and includes 2-D, Doppler, and color flow mapping.

† Since providers may not know the appropriate code/s that will be reported at the time of the pre-authorization request, they may request all 4 codes (CPT^® 93303, CPT^® 93320, CPT^® 93325, and CPT^® 93306).

† Depending upon individual health plan payer contracts, post-service audits may be completed to ensure proper claims submission.

† CPT^® 76376 and CPT^® 76377 are not unique to 3D Echo. These codes also apply to 3D rendering of MRI and CT studies. see CD-2.8: 3D Echocardiography – Coding

† CPT^® 93325 may also be used with fetal echocardiography.

CD-2.2: Transthoracic Echocardiography (TTE) – Indications

For this condition imaging is medically necessary based on the following criteria:

† TTE can be performed for the following:

® New or worsening cardiac signs or symptoms, including, but not limited to:
¡ Dyspnea
¡ Chest pain
¡ Palpitations
¡ Syncope
¡ Heart failure
¡ Murmur
® Hypertension – can be done once with initial evaluation
® New signs or symptoms of cerebral ischemia or peripheral embolic event
® Valve function and structure:
¡ History and/or physical examination suggesting significant valvular disorder
¡ Valve Surgery
§ If valve surgery is being considered can have TTE twice a year
§ Post-surgery at 6 weeks to establish baseline, then one routine study (surveillance) 3 years or more after valve surgery (repair or prosthetic valve implantation).
§ TAVR follow-up is indicated at, 1 month, and at one year post-procedure and annually thereafter.
— A baseline post-op TTE is usually performed within one week after surgery. This baseline study may also be approved as an outpatient if not performed in the hospital prior to discharge
— See: CD 4.8: Transcatheter Aortic Valve Replacement (TAVR)
§ Mitral valve clip follow-up may be approved at 1 month, at 6 months, and at one year post-procedure
® Ventricular function assessment including, but not limited to the following:
¡ Chemotherapy induced cardiomyopathy see: CD-12.1: Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD)
¡ Post myocardial infarction can be done once in follow-up. This should not be done less than 6 weeks post MI
¡ Evaluation prior to ICD/CRT placement, if baseline has not been established
® Cardiac structure: an echocardiogram can be done to assess cardiac structure when there are new or worsening cardiac signs or symptoms, suggesting disorders such as, but not limited to:
¡ Infiltrative diseases (e.g. sarcoid, amyloid)
¡ Ventricular septal defect (VSD)
¡ Papillary muscle rupture/dysfunction
¡ Hypertrophy including:
§ asymmetric septal hypertrophy
§ spade heart
§ hypertensive concentric hypertrophy
§ infiltrative hypertrophy
§ pacemaker insertion complication
§ pericardial effusion
§ cardiac injury due to blunt chest trauma
® Cardiac Defects or Masses
¡ Embolic source in members with recent Transient Ischemic Attack (TIA), stroke, or peripheral vascular emboli as an initial study before TEE.
¡ ASD repair or VSD repair:
§ Within the first year of surgery
§ Incomplete septal defect repair may be followed yearly
¡ Tumor evaluation including myxomas
¡ Clot detection
¡ Evaluation of adult congenital heart disease see also: Pediatric Cardiac Imaging Policy (Policy # 161 in the Radiology Section); PEDCD-2.2: Congenital Heart Disease
§ Routine yearly surveillance of adult congenital heart disease is allowed following incomplete or palliative repair, with residual abnormality and without a change in clinical status.
§ Screening for the presence of bicuspid aortic valve is recommended for first-degree relatives of members with bicuspid aortic valve.
§ Screening of the ascending aorta in known or suspected connective tissue disease that predisposes to an aortic aneurysm or dissection (e.g., Marfan syndrome, hereditary forms of ascending aortopathy)
§ Also see Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-2.2: Screening for vascular related genetic connective tissue Disorders (Familial Aneurysm Syndromes/Spontaneous Coronary Artery Dissection (SCAD)/Ehlers-Danlos/Marfan/Loeys-Dietz)
® Inflammatory
¡ Pericardial effusion/pericardial disease including pericardial cysts
¡ Congenital heart disease
¡ Endocarditis including:
§ Fever
§ Positive blood cultures indicating bacteremia or
§ A new murmur
® Pacemaker insertion complication
® Screening for first-degree relatives of members with hypertrophic cardiomyopathy (HCM)
¡ First-degree relatives who are 12 to 18 years old should be screened yearly for HCM by 2D- echocardiography, and ECG.
¡ First-degree relatives who are older than age 18 should have 2D-echo and ECG every five years to screen for delayed adult-onset LVH.
¡ Systematic screening is usually not indicated for first-degree relatives who are younger than age 12 unless there is a high-risk family history or the child is involved in particularly intense competitive sports.
¡ Affected individuals identified through family screening or otherwise should be evaluated every 12 to 18 months with 2D-echo, Holter monitor, and blood pressure response during maximal upright exercise.
® New abnormality on an EKG that has not been evaluated
® Thoracic aortic aneurysm/dissection see Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.2: Thoracic Aortic Aneurysm, Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.8: Aortic Dissection
® Members with BAVs and no demonstrable aortopathy may be followed every 3 years with TTE for the development of aortic enlargement

For this condition imaging is medically necessary based on the following criteria:

† Repeat routine echocardiograms are not supported (annually or otherwise) for evaluation of clinically stable syndromes

† Every three years, when there is a history of:

® Bicuspid aortic valve
® Mild aortic or mitral stenosis
® Prosthetic heart valve

® Significant valve dysfunction, including moderate or severe regurgitation or stenosis
® Significant valve deformity, such as thickened myxomatous valve or bileaflet prolapse, regardless of extent of regurgitation or stenosis
® Hypertrophic cardiomyopathy see CD-2.2: Transthoracic Echocardiography (TTE) – Indications, CD-2.7: Stress Echocardiography – Indications, other than ruling out CAD
® Chronic pericardial effusions
® Left ventricular contractility/diastolic function prior to planned medical therapy for heart failure or to evaluate the effectiveness of on-going therapy
® Pre-operative aortic root dilatation see CD 11.2.9 Congenital Valvular Aortic Stenosis
® Pulmonary hypertension (can be done more frequently with change in therapy)
® Systemic Scleroderma
® Prior TAVR

® Cardiac murmurs
® Myocardial infarction or acute coronary syndrome
® Congestive heart failure (new or worsening)
¡ New symptoms of dyspnea
¡ Orthopnea
¡ Paroxysmal nocturnal dyspnea
¡ Edema
¡ Elevated BNP
® Pericardial disease
® Stroke/transient ischemic attack
® Decompression illness
® Prosthetic valve dysfunction or thrombosis
® A history of prior cardiac transplant, per transplant center protocol

† Decisions regarding routine echocardiographic follow-up should not be based on the degree of regurgitation alone, but should take into account associated structural valvular and cardiac abnormalities. For example: a structurally normal mitral valve with moderate mitral regurgitation by color flow Doppler and normal left atrial size, does not generally require routine echocardiographic follow-up. However, a thickened, myxomatous appearing mitral valve with bi-leaflet prolapse and only trivial or mild mitral regurgitation, should be followed echocardiographically at routine intervals.

CD-2.4: Transesophageal Echocardiography (TEE) – Coding

For this condition imaging is medically necessary based on the following criteria:

Transesophageal Echocardiography		CPT®
TEE with 2-D, M-mode, probe placement, image acquisition, interpretation and report		93312
TEE probe placement only		93313
TEE image acquisition, interpretation, and report only		93314
TEE for congenital anomalies with 2-D, M-mode, probe placement, image acquisition, interpretation and report		93315
TEE for congenital anomalies, probe placement only		93316
TEE for congenital anomalies, image acquisition, interpretation and report only		93317
TEE for monitoring purposes, ongoing assessment of cardiac pumping function on an immediate time basis		93318
Doppler Echocardiography*		CPT®
Doppler echo, pulsed wave and/or spectral display		+93320
Doppler echo, pulsed wave and/or spectral display, follow-up or limited study		+93321
Doppler echo, color flow velocity mapping		+93325
*Doppler echo, if performed, may be reported separately in addition to the primary TEE codes: CPT® 93312, CPT® 93314, CPT® 93315, and CPT® 93317.
CPT®	Transesophageal Echocardiography
93312	TEE with 2-D, M-mode, probe placement, image acquisition, interpretation and report	C8925
93315	TEE for congenital anomalies with 2-D, M-mode, probe placement, image acquisition, interpretation and report	C8926
93318	TEE for monitoring purposes, ongoing assessment of cardiac pumping function on an immediate time basis	C8927

† The complete transesophageal echocardiogram service, including both (1) probe (transducer) placement and (2) image acquisition/interpretation, is reported with CPT^® 93312.

® Probe placement only is reported with CPT^® 93313.
® The image acquisition/interpretation only is reported with CPT^® 93314.

® Modifier -26 (professional component) is appended to the appropriate code
® CPT^® 93313 and CPT^® 93314 should never be used together. If both services are provided, CPT^® 93312 is reported.

† Monitoring of members undergoing cardiac surgery is CPT^® 93318.

CD-2.5: Transesophageal Echocardiography (TEE) – Indications

For this condition imaging is medically necessary based on the following criteria:

† Limited transthoracic echo window

† Assessing valvular dysfunction, especially mitral regurgitation, when TTE is inadequate

† Pre-operative planning for cardiac surgery

† Embolic source or intracardiac shunting when TTE is inconclusive

® Examples: atrial septal defect, ventricular septal defect, patent foramen ovale, aortic cholesterol plaques, thrombus in cardiac chambers, valve vegetation, tumor

® Clarify atria/atrial appendage, aorta, mitral/aortic valve beyond the information that other imaging studies have provided
® Cardiac valve dysfunction
¡ Differentiation of tricuspid from bicuspid aortic valve
¡ Congenital abnormalities

† Prior to planned atrial fibrillation ablation/pulmonary vein isolation procedure.

† Repeat TEE studies are based upon findings in the original study and documentation of the way in which repeat studies will affect member management, such as the following:

® Left Atrial appendage Closure device (e.g.,WATCHMAN^®)

¡ 45 days post procedure
¡ 12 months post procedure
® See also CD-13.5: Percutaneous Mitral Valve Repair (mitral valve clip)

For this condition imaging is medically necessary based on the following criteria:

Stress ECHO Procedure Codes
Stress Echocardiography	CPT®
Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report;*	93350
Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report: including performance of continuous electrocardiographic monitoring, with physician supervision*	93351
Doppler Echocardiography	CPT®
Doppler echo, pulsed wave and/or spectral display**	+93320
Doppler echo, pulsed wave and/or spectral display, follow-up/limited study	+93321
Doppler echo, color flow velocity mapping**	+93325
*CPT® 93350 and CPT® 93351 do not include Doppler studies
*Doppler echo (CPT® +93320 and CPT® +93325), if performed, may be reported separately in addition to the primary SE codes: CPT® 93350 or CPT® 93351.

CPT®	Stress Echocardiography
93350	Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report;*	C8928
93351	Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report: including performance of continuous electrocardiographic monitoring, with physician supervision*	C8930

CD-2.7: Stress Echocardiography–Indications, other than ruling out CAD

For this condition imaging is medically necessary based on the following criteria:

† See: CD-1.4: Stress Testing with Imaging – Indications . In addition to the evaluation of CAD, stress echo can be used to evaluate the following conditions:

® Dyspnea on exertion (specifically to evaluate pulmonary hypertension)
® Right heart dysfunction
® Valvular heart disease, especially when the outcome would affect a therapeutic or interventional decision
® Pulmonary hypertension, when the outcome will measure response to therapy and/or prognostic information
® Hypertrophic cardiomyopathy
¡ In a member with a history of hypertrophic cardiomyopathy who has been previously evaluated with a stress echo, another stress echo may be appropriate if there are worsening symptoms or if there has been a therapeutic change (for example: change in medication, surgical procedure performed).

CD-2.8: 3D Echocardiography – Coding

For this condition imaging is medically necessary based on the following criteria:

† The procedure codes used to report 3D rendering for echocardiography are not unique to echocardiography and are the same codes used to report the 3D post-processing work for CT, MRI, ultrasound, and other tomographic modalities.

® CPT^® 76376, not requiring image post-processing on an independent workstation, is the most common code used for 3D rendering done with echocardiography
® CPT^® 76377 requires the use of an independent workstation

For this condition imaging is medically necessary based on the following criteria:

† Echocardiography with 3-dimensional (3D) rendering is becoming universally available, yet its utility remains limited based on the current literature.

† 3D Echo may be indicated when an primary echocardiogram is approved and one of the following is needed:

® Left ventricular volume and ejection fraction assessment when measurements are needed for treatment decision (e.g. implantation of ICD, alteration in cardiotoxic chemotherapy)
® Mitral valve anatomy specifically related to mitral valve stenosis
® Guidance of transcatheter procedures

For this condition imaging is medically necessary based on the following criteria:

† (CPT^® 93356) Investigational see CD-2.1: Transthoracic Echocardiography (TTE) – Coding

CD-2.11: Myocardial contrast perfusion echocardiography

For this condition imaging is medically necessary based on the following criteria:

† (CPT^® 0439T) Investigational see CD-2.1: Transthoracic Echocardiography (TTE) – Coding

References
1. Bangalore S, Yao S-S, Chaudhry FA. Usefulness of Stress Echocardiography for Risk Stratification and Prognosis of Patients with Left Ventricular Hypertrophy. The American Journal of Cardiology. 2007;100(3):536-543. doi:10.1016/j.amjcard.2007.03.057.
2. Douglas PS, Khandheria B, Stainback RF, Weissman NJ. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress EchocardiographyDeveloped in accordance with the principles and methodology outlined by ACCF: Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED, Wolk MJ, Allen JM, Raskin IE. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 2005;46:1606–13. Journal of the American College of Cardiology. 2008;51(11):1127-1147. doi:10.1016/j.jacc.2007.12.005.
3. Maron B. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. European Heart Journal. 2003;24(21):1965-1991. doi:10.1016/s0195-668x(03)00479-2.
4. Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography. Journal of the American College of Cardiology. 2007;49(2):227-237. doi:10.1016/j.jacc.2006.08.048.
5. Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography. Journal of the American Society of Echocardiography. 2007;20(9):1021-1041. doi:10.1016/j.echo.2007.07.003.
6. Tandoðan I, Yetkin E, Yanik A, et al. Comparison of thallium-201 exercise SPECT and dobutamine stress echocardiography for diagnosis of coronary artery disease in patients with left bundle branch block. The International Journal of Cardiac Imaging. 2001;17(5):339-345. doi:10.1023/a:1011973530231.
7. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. Circulation. 2014;129(23):2440-2492. doi:10.1161/cir.0000000000000029.
8. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Journal of the American Society of Echocardiography. 2010;23(7):685-713. doi:10.1016/j.echo.2010.05.010.
9. Holmes DR, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement. The Annals of Thoracic Surgery. 2012;93(4):1340-1395. doi:10.1016/j.athoracsur.2012.01.084.
10. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound. Journal of the American Society of Echocardiography. 2009;22(9):975-1014. doi:10.1016/j.echo.2009.07.013.
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. Journal of the American College of Cardiology. 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.009.
12. Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease. Journal of the American College of Cardiology. 2017;70(13):1647-1672. doi:10.1016/j.jacc.2017.07.732.
13. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(23). doi:10.1161/circulationaha.108.190690.
14. Khanna D, Gladue H, Channick R, et al. Recommendations for Screening and Detection of Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Arthritis & Rheumatism. 2013;65(12):3194-3201. doi:10.1002/art.38172.
15. Simonneau G, Gatzoulis MA, Adatia I, et al. Updated Clinical Classification of Pulmonary Hypertension. Journal of the American College of Cardiology. 2013;62(25). doi:10.1016/j.jacc.2013.10.029.
16. Tolle JJ, Waxman AB, Horn TLV, Pappagianopoulos PP, Systrom DM. Exercise-Induced Pulmonary Arterial Hypertension. Circulation. 2008;118(21):2183-2189. doi:10.1161/circulationaha.108.787101.
17. Vainrib AF, Harb SC, Jaber W, et al. Left Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography. Journal of the American Society of Echocardiography. 2018;31(4):454-474. doi:10.1016/j.echo.2017.09.014.

CD-3: Nuclear Cardiac Imaging

CD-3.1: Myocardial Perfusion Imaging (MPI) – Coding

CD-3.2: MPI – Indications

CD-3.3: MUGA – Coding

CD-3.4: MUGA Study – Cardiac Indications

CD-3.5: MUGA Study – Oncologic Indications for Cancer Therapeutics - Related Cardiac Dysfunction (CTRCD)

CD-3.6: Myocardial Sympathetic Innervation Imaging in Heart Failure

CD-3.7: Myocardial Tc-99m Pyrophosphate Imaging

CD-3.8: Cardiac Amyloidosis

CD-3.1: Myocardial Perfusion Imaging (MPI) – Coding

For this condition imaging is medically necessary based on the following criteria:

Nuclear Cardiac Imaging Procedure Codes
Myocardial Perfusion Imaging (MPI)	CPT®
MPI, 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)	78451
MPI, 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	78452

† The most commonly performed myocardial perfusion imaging are single (at rest or stress, CPT^® 78451) and multiple (at rest and stress, CPT^® 78452) SPECT studies.

® Evaluation of the individual’s left ventricular wall motion and ejection fraction are routinely performed during MPI and are included in the code’s definition.
® First pass studies, (CPT^® 78481 and CPT^® 78483), MUGA, (CPT^® 78472 and CPT^® 78473) and SPECT MUGA (CPT^® 78494) should not be reported in conjunction with MPI codes.
® Attenuation correction, when performed, is included in the MPI service by code definition. No additional code should be assigned for the billing of attenuation correction.

† 3D rendering, (CPT^® 76376/CPT^® 76377), should not be billed in conjunction with MPI.

† Separate codes for such related services as treadmill testing (CPT^® 93015 ^- CPT^® 93018) and radiopharmaceuticals should be assigned in addition to MPI. These services are reimbursed according to each individual payer policy.

CD-3.2: MPI – Indications

For this condition imaging is medically necessary based on the following criteria:

† See: CD-1.4: Stress Testing with Imaging-Indications

CD-3.3: MUGA – Coding

For this condition imaging is medically necessary based on the following criteria:

Nuclear Cardiac Imaging Procedure Codes
MUGA (Multi Gated Acquisition) – Blood Pool Imaging	CPT®
Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress, wall motion study plus ejection fraction, with or without quantitative processing	78472
Cardiac blood pool imaging, gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction, at rest and stress, with or without additional quantification	78473
Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing	78494
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) [Use in conjunction with CPT® 78472]	+78496

† The technique employed for a MUGA service guides the code assignment. CPT^® 78472 is used for a planar MUGA scan at rest or stress, and CPT^® 78473 for planar MUGA scans, multiple studies at rest and stress.

† The two most commonly performed MUGA scans are the studies defined by CPT^® 78472 and SPECT MUGA, CPT^® 78494.

† Planar MUGA studies (CPT^® 78472 and CPT^® 78473) should not be reported in conjunction with:

® MPI (CPT^® 78451 - CPT^® 78454)
® First pass studies (CPT^® 78481- CPT^® 78483), and/or
® SPECT MUGA (CPT^® 78494).

® See: CD-3.4: MUGA Study – Cardiac Indications
® This add-on code should not be performed as a routine protocol.

For this condition imaging is medically necessary based on the following criteria:

MUGA (Multi Gated Acquisition) – Blood Pool Imaging Indications

† Echocardiography is the preferred method of following left ventricular systolic function. Indications below refer to scenarios in which MUGA may be performed rather than ECHO:

® Prior ECHO demonstrates impaired systolic function (EF < 50%).
® Pre-existing left ventricular wall motion abnormalities from ischemic heart disease or ischemic or non-ischemic cardiomyopathies.
® ECHO is technically limited and prevents accurate assessment of LV function.
® AICD placement:
¡ MUGA to assess LV ejection fraction when there are conflicting results between other forms of testing and the issue is clinically relevant, e.g., MPI LVEF is 80% and an echo EF is 30%, the MUGA would be appropriate.
¡ However, if the MPI LVEF is 80% and the echo EF is 50%, this would not be appropriate even though the difference is significant since the echo EF is still normal.
® Congestive heart failure:
¡ MUGA to measure response to cardiac medications for CHF if echocardiogram was performed and was technically difficult
® Previous low LV ejection fraction determination was < 50% and receiving potentially cardiotoxic chemotherapy
® Documentation of other need for information given by MUGA that cannot be obtained by ECHO

MUGA is NOT indicated for the following:

† A prior MUGA is not a reason to approve another MUGA (it is not necessary to compare LVEF by the same modality)

† To resolve differences in ejection fraction measurements between ECHO and MPI unless there is clear documentation as to how quantitative measurement of LVEF will affect member management (e.g. implantation of an AICD).

Practice Notes:

† LV ejection fraction measurement is variable and can vary by ^+/-5-10% without any accompanying change in clinical status. Normal physiologic changes in intravascular volume, catecholamine levels, fever, and medications are among the many factors which cause variation in LVEF in the absence of myocardial pathology.

† Right ventricular first pass study, (CPT^® +78496), may be indicated if there is clear documentation of a concern regarding right ventricular dysfunction or overload.

CD-3.5: MUGA Study – Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD)

For this condition imaging is medically necessary based on the following criteria:

† See CD 12.1: Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD)

CD-3.6: Myocardial Sympathetic Innervation Imaging in Heart Failure

For this condition imaging is medically necessary based on the following criteria:

† In heart failure, the sympathetic nervous system is activated in order to compensate for the decreased myocardial function. Initially, this is beneficial, however, long-term this compensatory mechanism is detrimental and causes further damage.

† Markers have been developed, using radioactive iodine, in an attempt to image this increased myocardial sympathetic activity. Currently, AdreView^™ (Iodine-123 meta-iodobenzylguanidine), is the only FDA-approved imaging agent available for this purpose. eviCore currently considers AdreView to be experimental and investigational.

† The AMA has established the following set of Category III codes to report these studies:

® 0331T - Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment
® 0332T - Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT.

For this condition imaging is medically necessary based on the following criteria:

Myocardial Tc-99m Pyrophosphate Imaging
MUGA (Multi Gated Acquisition) – Blood Pool Imaging	CPT®
Myocardial Imaging, infarct avid, planar, qualitative or quantitative	78466
Myocardial Imaging, infarct avid, planar, qualitative or quantitative with ejection fraction by first pass technique	78468
Myocardial Imaging, infarct avid, planar, qualitative or quantitative tomographic SPECT with or without quantification	78469
Radiopharmaceutical Localization Imaging Limited area	78800
Radiopharmaceutical Localization Imaging SPECT Note: When reporting CPT® 78803, planar imaging of a limited area or multiple areas should be included with the SPECT	78803

† Historically this method of imaging the myocardium was used to identify recent infarction, hence, the term "infarct-avid scan.” Although still available, the sensitivity and specificity for identifying infarcted myocardial tissue are variable and the current use for this indication is limited. See CD-5: Cardiac MRI.

CD-3.8: Cardiac Amyloidosis

For this condition imaging is medically necessary based on the following criteria:

† Tc-99m pyrophosphate imaging may be used to identify cardiac amyloidosis (CPT^® 78803). Chest SPECT and planar imaging may be used, as well as whole-body imaging for identification of systemic ATTR (transthyretin) amyloidosis.

† For a single planar imaging session alone (without a SPECT study), report CPT^® 78800 Radiopharmaceutical Localization Imaging Limited area

† Tc-99m pyrophosphate imaging may be indicated to identify cardiac amyloidosis for any of the following:

® Individuals with heart failure and unexplained increase in left ventricular wall thickness.
® African-Americans over the age of 60 years with heart failure, unexplained or with increased left ventricular wall thickness (> 12 mm).
® Individuals over the age of 60 years with unexplained heart failure and preserved ejection fraction.
® Individuals, especially elderly males, with unexplained neuropathy, bilateral carpal tunnel syndrome or atrial arrhythmias in the absence of usual risk factors, and signs/symptoms of heart failure.
® Evaluation of cardiac involvement in individuals with known or suspected familial amyloidosis.
® Diagnosis of cardiac ATTR in individuals with CMR or echocardiography consistent with cardiac amyloidosis.
® Members with suspected cardiac ATTR amyloidosis and contraindications to CMR such as renal insufficiency or an implantable cardiac device.¹⁴

For this condition imaging is medically necessary based on the following criteria:

† The high negative predictive value (98%-99%) of CCTA in ruling out significant coronary artery disease has been confirmed in multiple studies.

Cardiac Imaging Procedure Codes
Cardiac CT	CPT®
CT, heart, without contrast, with quantitative evaluation of coronary calcium	75571
The code set for Cardiac CT and CCTA (CPT® 75572-CPT® 75574), include quantitative and functional assessment (for example, calcium scoring) if performed
CPT® 75571 describes a non-contrast CT of the heart with calcium scoring and should be reported only when calcium scoring is performed as a stand-alone procedure. † Can be used to report a preliminary non-contrast scan which indicates an excessive amount of calcium such that the original scheduled study must be discontinued. † CPT® 75571 should not be reported in conjunction with any of the contrast CT/CTA codes (CPT® 75572- CPT® 75574).
Cardiac CT and CCTA	CPT®
CT, heart, with contrast, for evaluation of cardiac structure and morphology (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).	75572
CT, heart, with contrast, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).	75573
CTA, heart, coronary arteries and bypass grafts (when present), with contrast, including 3D image post-processing (including 3D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed).	75574
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report	0501T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission	0502T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model	0503T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report	0504T

† 3D rendering, (CPT^® 76376/CPT^® 76377), should not be billed in conjunction with Cardiac CT and CCTA.

† Only one code from the set: CPT^® 75572 - CPT^® 75574 can be reported per encounter.

† CPT^® 75574 includes evaluation of cardiac structure and morphology when performed; therefore, additional code/s should not be assigned.

CD-4.2: CT for Coronary Calcium Scoring (CPT^® 75571)

For this condition imaging is medically necessary based on the following criteria:

CD-4.2.1: CT Calcium Scoring for CAD Screening

† Coronary artery calcium scoring (75571)

® No coronary calcium scoring in the last 5 years, no prior abnormal imaging stress test, coronary revascularization or prior catheterization or cardiac CT angiogram documenting coronary artery disease [And one of the following]
¡ ATP* risk <10 percent and [One of the following]
§ Father or brother with coronary heart disease diagnosed at age 55 or less
§ Mother or sister with coronary heart disease diagnosed at age 65 or less
¡ ATP* risk 10-19 percent AND
§ No symptoms of chest pain or shortness of breath

† Texas Heart Attack Preventive Screening Law (HR 1290) mandates that insurers in Texas cover either a calcium scoring study (CPT^® 75571 or HCPCS S8092) or a carotid intima-media thickness study (ultrasound—Category III code 0126T) every five years for certain populations. To qualify, the following must apply:

® Must be a Texas resident.
® Must be a member of a fully-insured Texas health plan.
® Must be a man age 45 to 75 or a woman age 55 to 75.
® Must have either diabetes or a Framingham cardiac risk score of intermediate or higher.
® Must not have had a calcium scoring study or a carotid intima-media thickness study within the past 5 years.

† Symptomatic individuals with a ‘very low’, or ‘low’ pretest probability of CAD*, see Table 1 in CD-1.1: General Issues – Cardiac

CD-4.3: CCTA – Indications for CCTA

For this condition imaging is medically necessary based on the following criteria:

† Symptomatic individuals who have a ‘low’ or ‘intermediate’ pretest probability of CAD*, see Table 1 in CD-1.1: General Issues – Cardiac

† ‘Low’ or ‘intermediate’ pre-test probability of coronary disease with persistent symptoms after a stress test.

† Replace performance of invasive coronary angiogram in individuals with low risk of CAD (i.e. Pre-op non-coronary surgery).

† For symptomatic individuals, evaluate post-CABG graft patency when only graft patency is a concern and imaging of the native coronary artery anatomy is not needed, such as in early graft failure.

CD-4.4: CCTA – Additional Indications

For this condition imaging is medically necessary based on the following criteria:

† Re-do CABG

® To identify whether bypass grafts are located directly beneath the sternum, so that alternative ways to enter the chest can be planned.

® Report CPT^® 75574 for evaluating coronary artery anomalies.
® Report CPT^® 75573 for congenital heart disease.
¡ To evaluate the great vessels, Chest CTA (CPT^® 71275) can be performed instead of CCTA or in addition to CCTA. For anomalous pulmonary venous return, can add CT abdomen and pelvis with contrast (CPT^® 74177).

® Persistent exertional chest pain and normal stress test,
® Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery
® Resuscitated sudden death and contraindications for conventional coronary angiography
® Prior nondiagnostic coronary angiography in determining the course of the anomalous coronary artery in relation to the great vessels, origin of a coronary artery or bypass graft location.

† Evaluation of newly diagnosed congestive heart failure or cardiomyopathy.

® No prior history of coronary artery disease, the ejection fraction is less than 50 percent, and low or intermediate risk on the pre-test probability assessment, and
® No exclusions to cardiac CT angiography.
® No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has been performed since the diagnosis of congestive heart failure or cardiomyopathy.

† Equivocal coronary artery anatomy on conventional cardiac catheterization.

† Newly diagnosed dilated cardiomyopathy.

† Preoperative assessment of the coronary arteries in members who are going to undergo surgery for aortic dissection, aortic aneurysm, or valvular surgery if CCTA will replace conventional invasive coronary angiography.

† Vasculitis/Takayasu’s/Kawasaki’s disease

† Cardiac Trauma: Chest CTA (CPT^® 71275) and CCTA (CPT^® 75574) are useful in detecting aortic and coronary injury and can help in the evaluation of myocardial and pericardial injury see CD-10.1: Cardiac Trauma – Imaging

CD-4.5: Fractional Flow Reserve by Computed Tomography

For this condition imaging is medically necessary based on the following criteria:

† Fractional flow reserve (FFR) is typically measured using invasive techniques. FFR can be obtained noninvasively from coronary computed tomography angiography data (FFR-CT).

† Indications for FFR-CT

® To further assess CAD seen on a recent CCTA that is of uncertain physiologic significance

For this condition imaging is medically necessary based on the following criteria:

† Cardiac vein identification for lead placement in members needing left ventricular pacing.

† Pulmonary vein isolation procedure (ablation) for atrial fibrillation

® Cardiac MRI (CPT^® 75557 or CPT^® 75561), chest MRV (CPT^® 71555), chest CTV (CPT^® 71275), or cardiac CT (CPT^® 75572) can be performed to evaluate the anatomy of the pulmonary veins prior to an ablation procedure performed for atrial fibrillation.
® Study may be repeated post-procedure between 3-6 months after ablation because of a 1%-2% incidence of asymptomatic pulmonary vein stenosis
® See CD-8.2: Pulmonary Vein Imaging – Indications

® Cardiac or pericardial tumor or mass
® Cardiac thrombus
® Pericarditis/constrictive pericarditis
® Complications of cardiac surgery

† Recurrent laryngeal nerve palsy due to cardiac chamber enlargement.

† Coronary imaging is not included in the code definition for CPT^® 71275.

® The AMA definition for CPT^® 71275 reads: “CTA Chest (non-coronary), with contrast material(s), including non-contrast images, if performed, and image post-processing.”

For this condition imaging is medically necessary based on the following criteria:

† Coronary artery anomaly evaluation

® A cardiac catheterization was performed, and not all coronary arteries were identified.

® A cardiac MRI or chest CT angiogram was performed and suggested congenital heart disease.

® No cardiac CT or cardiac MRI has been performed, and there is a contraindication to cardiac MRI.
® A cardiac CT or cardiac MRI was performed one year ago or more.

For this condition imaging is medically necessary based on the following criteria:

† Once the decision has been made for aortic valve replacement, the following may be used to determine if a member is a candidate for TAVR:

® CTA of chest (CPT^® 71275), abdomen and pelvis (combination code CPT^® 74174) are considered appropriate, and
® Cardiac CT (CPT^® 75572) may be considered to measure the aortic annulus ² or
® Coronary CTA (CCTA CPT^® 75574) may be considered to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization.

† TTE follow-up is indicated at:

® A baseline post-op TTE is indicated within one week after surgery if not performed in the hospital prior to discharge.
® 1 month
® One year post-procedure
® Then annually thereafter.

CD-5.1: Cardiac MRI – Coding

For this condition imaging is medically necessary based on the following criteria:

Cardiac Imaging Procedure Codes
CARDIAC MRI	CPT®
Cardiac magnetic resonance imaging for morphology and function without contrast	75557
Cardiac magnetic resonance imaging for morphology and function without contrast; with stress imaging	75559
Cardiac magnetic resonance imaging for morphology and function without and with contrast and further sequences	75561
Cardiac magnetic resonance imaging for morphology and function without and with contrast and further sequences; with stress imaging	75563
Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)	+75565

† Only one procedure code from the set (CPT^® 75557- CPT^® 75563) should be reported per session.

† Only one flow velocity measurement (CPT^® +75565) should be reported per session when indicated.

® Requests for cardiac MRI that contain more than one cardiac/chest MRI CPT^® Code must be forwarded for Medical Director Review.

For this condition imaging is medically necessary based on the following criteria:

† Assess myocardial viability (to differentiate hibernating myocardium from scar) when necessary to determine if revascularization should be performed (CPT^® 75561)

† Assessment of global ventricular function and mass if a specific clinical question is left unanswered by a recent echocardiogram and results will affect member management (CPT^® 75557 or CPT^® 75561). Particularly useful in evaluating:

® Cardiomyopathy (ischemic, diabetic, hypertrophic, or muscular dystrophy)
® Noncompaction
® Amyloid heart disease
® Post cardiac transplant
® Hemochromatosis
® Post transfusion hemosiderosis
® Hypertrophic heart disease
® Myocarditis, cardiac aneurysm, trauma, and contusions
® Monitoring cancer chemotherapy effect on the heart (especially if an accurate assessment of right ventricular function is documented as necessary).

® Chest MRA (CPT^® 71555) may be added if the aorta or pulmonary artery need to be visualized beyond the root.
® Report CPT^® +75565 in conjunction with CPT^® 75557 or CPT^® 75561, only if there is a need to clarify findings on a recent echocardiogram and cardiac Doppler study.

† Coarctation of the aorta

® Follow-up (surveillance) imaging after repair of coarctation:
¡ Adults: chest MRA (CPT^® 71555) every 2 to 3 years and before and after any intervention for re-coarctation
¡ Infants and children: ECHO every month for several months, then ECHO every 6 months to one year thereafter

† Differentiate constrictive pericarditis from restrictive cardiomyopathy (CPT^® 75561).

† Evaluate cardiac tumor or mass when echocardiogram is inconclusive.

† Initial evaluation for cardiac sarcoidosis.

† Anomalous coronary arteries: Cardiac MRI (CPT^® 75561) or CCTA (CPT^® 75574) is much better at detecting this than conventional angiography.

† Assess coronary arteries in Kawasaki’s disease.

† Fabry disease

® Late enhancement MRI may predict the effect of enzyme replacement therapy on myocardial changes that occur with this disease (CPT^® 75561).

® CPT^® 75557 or CPT^® 75561 and
® CPT^® 75565

† Suspected cardiac thrombus when echocardiogram is inconclusive (CPT^® 75557).

† Right ventricular function evaluation (CPT^® 75557 in conjunction with CPT^® +75565) if a recent ECHO has been done, and there is documented need to perform cardiac MRI in order to resolve an unanswered question.

† Shunting through a VSD (CPT^® 75557 in conjunction with CPT^® +75565) if a recent ECHO has been done, including a bubble study, and there is documented need to perform cardiac MRI in order to resolve an unanswered question.

† Evaluate for iron overload due to conditions requiring frequent blood transfusions (i.e. sickle cell, thalassemia, hemochromatosis, etc.) (CPT^® 75557).

CD-5.3: Cardiac MRI – Indications for Stress MRI

For this condition imaging is medically necessary based on the following criteria:

† For indications for Stress MRI see CD-1.4: Stress Testing with Imaging – Indications. Also, if a nuclear perfusion (MPI) stress test was performed and was equivocal, a stress MRI is appropriate.

CD-5.4: Cardiac MRI – Aortic Root and Proximal Ascending Aorta

For this condition imaging is medically necessary based on the following criteria:

† See- PVD-6.2: Thoracic Aortic Aneurysm (TAA)

CD-5.5: Cardiac MRI – Evaluation of Pericardial Effusion or Diagnosis of Pericardial Tamponade

For this condition imaging is medically necessary based on the following criteria:

† Contrast-enhanced cardiac MRI (CPT^® 75561) is useful for evaluating pericarditis, neoplastic and other effusion, tamponade or myocardial infiltration if a specific clinical question is left unanswered by echocardiogram or another recent imaging study.

References
1. Cheong BYC, Muthupillai R, Wilson JM, et al. Prognostic significance of delayed-enhancement magnetic resonance imaging. Circulation. 2009; 120:2069-2076. doi:10.1161/CIRCULATIONAHA.109.852517.
2. Dalal D, Nasir K, Bomma C, et al. Arrhythmogenic right ventricular dysplasia: a United States experience. Circulation 2005; 112(25):3823-3832. doi:10.1161/CIRCULATIONAHA.105.542266.
3. Hamdan A, Charalampos K, Roettgen R, et al. Magnetic resonance imaging versus computed tomography for characterization of pulmonary vein morphology before radiofrequency catheter ablation of atrial fibrillation. Am J Cardiol, 2009; 104:1540-1546. doi:10.1016/j.amjcard.2009.07.029
4. Hendel RC, Kramer CM, Patel MR, et al. ACCF/ACR/SCCT/SCMR/ ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for computed tomography and cardiac magnetic resonance imaging. J Am CollCardiol,2006; 48(7):1475-1497. Accessed November 30, 2017. doi :10.1016/j.jacc.2006.07.003.
5. Kapoor WN, Smith MA, Miller NL. Upright tilt testing in evaluating syncope: a comprehensive literature review. Am J Med, 1994 July; 97:78-88. doi:10.1016/0002-9343(94)90051-5.
6. Ramaraj R, Sorrell VL, Marcus F, et al. Recently defined cardiomyopathies: A clinician’s update. The American Journal of Medicine, 2008; 121:674-681. doi:10.1016/j.amjmed.2008.02.037.
7. Raviele A, Proclemer A, Gasparini G, et al. Long-term follow-up of patients with unexplained syncope and negative electrophysiologic study. Eur Heart J 1989; 10:127-132. doi:10.1093/oxfordjournals.eurheartj.a059452
8. Strickberger SA, Benson DW, Biaggiono I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006; 113:316-327. doi:10.1161/CIRCULATIONAHA.105.170274.
9. Woodard PK, Bluemke DA, Cascade PN, et al. ACR^® Practice Guideline for the performance and interpretation of cardiac magnetic resonance imaging (MRI). J Am CollRadiol 2006 :665-676. doi:10.1016/j.jacr.2006.06.007.
10. Woodard PK, Bluemke DA, Cascade PN, et al. ACR^® Practice Guideline for the performance and interpretation of cardiac magnetic resonance imaging (MRI). J Am CollRadiol 2006:665-676. https://doi.org/10.1016/j.jacr.2006.06.007.
11. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e714. doi:10.1161/CIRCULATIONAHA.108.190811.

CD-6: Cardiac PET

CD-6.1: Cardiac PET – Coding

CD-6.2: Cardiac PET – Perfusion - Indications

CD-6.3: Cardiac PET – Absolute Quantitation of Myocardial Blood Flow

CD-6.4: Cardiac PET – Metabolic – Indications

CD-6.1: Cardiac PET – Coding

For this condition imaging is medically necessary based on the following criteria:

Cardiac Imaging Procedure Codes
CARDIAC PET	CPT®
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study	78459
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study at rest or stress (exercise or pharmacologic)	78491
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic)	78492
Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan	78429
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan	78430
Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan	78431
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (e.g., myocardial viability);	78432
Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (e.g., myocardial viability); with concurrently acquired computed tomography transmission scan	78433
Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)	78434

† 3D rendering, (CPT^® 76376/CPT^® 76377), should not be billed in conjunction with PET.

† Separate codes for such related services as treadmill testing (CPT^® 93015^-CPT^® 93018) and radiopharmaceuticals should be assigned in addition to perfusion PET. These services are paid according to each individual payer.

† 78434 is an add-on code for cardiac PET perfusion and is considered investigational

CD-6.2: Cardiac PET – Perfusion – Indications

For this condition imaging is medically necessary based on the following criteria:

† CPT^® 78430, 78431, 78491, and CPT^® 78492

† Meets all of the criteria for an imaging stress test and additionally any one of the following:

® Individual is obese (for example BMI >40 kg/m²) or
® Individual has large breasts or implants

† Routine use in post heart transplant assessment of transplant CAD

† CMS (Medicare) does not cover reporting for wall motion and ejection fraction performed in conjunction with cardiac perfusion PET. There is not a separate CPT^® or HCPCS code associated with these specific services. eviCore and their partner health plans adhere to the CMS policy unless explicitly stated in the health plan’s coverage policy.

CD-6.3: Cardiac PET – Absolute quantitation of myocardial blood flow

For this condition imaging is medically necessary based on the following criteria:

† CPT^® 78434

† Performance of quantitation of myocardial blood flow by Cardiac PET is currently non-standardized between different vendor products.

† Absolute quantitation of myocardial blood flow is considered experimental, investigational and/or unproven (EIU).

CD-6.4: Cardiac PET – Metabolic – Indications

For this condition imaging is medically necessary based on the following criteria:

† Cardiac PET Metabolic (CPT^® 78459 or CPT^® 78429)

® To determine myocardial viability when a previous study has shown significant left ventricular dysfunction when under consideration for revascularization

® To identify and monitor response to therapy for established or strongly suspected cardiac sarcoid.

For this condition imaging is medically necessary based on the following criteria:

Cardiac Catheterization Procedure Codes
Cardiac Cath Procedures	CPT®
Congenital Heart Disease Code “Set”	93530-93533
Right Heart Catheterization (CHD)	93530
Right/Left Heart Catheterization (CHD)	93531
Right/Left Heart Catheterization (CHD-TS)	93532
Right/Left Heart Catheterization (CAD-ASD)	93533
Anomalous coronary arteries, patent foramen ovale, mitral valve prolapse, and bicuspid aortic valve	93451-93464, 93566-93568
RHC without LHC or coronaries	93451
LHC without RHC or coronaries	93452
RHC and retrograde LHC without coronaries	93453
Native coronary artery catheterization;	93454
with bypass grafts	93455
with RHC	93456
with RHC and bypass grafts	93457
with LHC	93458
with LHC and bypass grafts	93459
with RHC and LHC	93460
with RHC and LHC and bypass grafts	93461
LHC by trans-septal or apical puncture	+93462
Angiography of non-coronary arteries and veins performed as a distinct service	Select appropriate codes from the Radiology and Vascular Injection Procedures sections.

† CPT^® 93530 to 93533 are appropriate for invasive evaluation of congenital heart disease. See also specific conditions in CD-11: Adult Congenital Heart Disease

CD-7.2: Diagnostic Heart Catheterization – Coding Notes

For this condition imaging is medically necessary based on the following criteria:

Cardiac catheterization (CPT® 93451-CPT® 93461) includes all “road mapping” angiography necessary to place the catheters, including any injections and imaging supervision, interpretation, and report.

Cardiac catheterization (CPT® 93452-CPT® 93461) (for all conditions other than congenital heart disease) includes contrast injections, imaging supervision, interpretation, and report for imaging typically performed.

Catheter placements in native coronaries or bypass grafts (CPT® 93454-CPT® 93461) include intraprocedural injections for bypass graft angiography, imaging supervision, and interpretation.

Injection codes CPT® 93563-CPT® 93565 should not be used in conjunction with CPT® 93452-CPT® 93461.

Codes CPT® 93451-CPT® 93461 do not include contrast injections and imaging supervision, interpretation, and report for imaging that is separately identified by the following specific procedure codes: CPT® 93566, CPT® 93567 and CPT® 93568.

† Separate diagnostic cardiac catheterization codes should only be assigned in conjunction with interventional procedures in the following circumstances: ® No prior or recent diagnostic catheterization is available to guide therapy ® Individual’s condition has significantly changed since the last diagnostic cath ® The treatment plan may be affected ® Other vessels may be identified for treatment ® Further establishment of a diagnosis from a non-invasive study is necessary

CD-7.3: Diagnostic Left Heart Catheterization (LHC)

For this condition imaging is medically necessary based on the following criteria:

CD-7.3.1: Diagnostic Left Heart Catheterization (LHC) – general information

† Individuals in acute settings or with active unstable angina should be handled as medical emergencies.

† These guidelines apply to individuals with stable conditions and who are not in the acute setting (acute coronary syndrome or unstable angina).

† Diagnostic Left Heart Catheterization (LHC) is indicated to identify disease for which invasive procedures have been shown to prolong survival:

® Left main coronary artery disease plus right coronary artery disease plus left ventricular dysfunction.

® Triple vessel coronary artery disease plus left ventricular dysfunction.

® Iliac/femoral artery angiography when dissection or obstruction to the passage of the catheter/guidewire is encountered.
® Renal arteriography if the criteria outlined in the Abdomen Imaging Guidelines are met see Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-6.5: Renovascular Hypertension.

† LHC may be indicated for any of the following when there is new onset, persistent, or worsening of angina symptoms:

® A recent history of unstable angina- symptoms suggestive of acute coronary syndrome (ACS) occurring at rest, or with minimal exertion resolving with rest:
¡ new onset, accelerating, or worsening ischemic symptoms that are suggestive of unstable angina
¡ new onset, accelerating, or worsening symptoms consistent with member’s known angina pattern in an individual with a history of CABG or PCI
® Symptomatic members with a high pretest probability of CAD:
¡ see CD-1.1: General Issues – Cardiac, Pre-Test Probability Grid (Table 1)
® Symptoms concerning for coronary artery ischemia (chest discomfort, shortness of breath, etc.) with evidence of significant ischemia on recent stress testing, such as:
¡ At least moderate ischemia (medium to large size defect) on imaging stress test
¡ At least moderate size area of hypokinesis on stress echo
® Persistent or worsening symptoms to evaluate progression of known CAD when:
¡ Recent noninvasive cardiac testing was equivocal, unsuccessful in delineating the clinical problem, or led to a conclusion that intervention is indicated
¡ Angina that is unresponsive to optimized medical therapy see CD-1.1: General Issues – Cardiac and for which invasive procedures are needed to provide pain relief.

® Left ventricular dysfunction (congestive heart failure) in members suspected of having coronary artery disease.
® Ventricular fibrillation or sustained ventricular tachycardia where the etiology is unclear.
® Unheralded syncope (not near syncope) where the etiology is unclear.
® Recent noninvasive cardiac testing was equivocal, unsuccessful in delineating the clinical problem, or led to a conclusion that intervention is indicated for the following conditions:
¡ Cardiomyopathy
¡ Suspicion of endocarditis, or myocarditis
¡ Significant/serious ventricular arrhythmia
¡ An intermediate or large amount of myocardium (>5%) may be in jeopardy
¡ Evaluation of coronary grafts
¡ Evaluation of previously placed coronary artery stents
¡ Evaluation of structural disease
® Evaluation prior to planned surgery
¡ Ruling out coronary artery disease prior to planned non-coronary cardiac or great vessel surgery (i.e. cardiac valve surgery, aortic dissection, aortic aneurysm, congenital disease repair such as atrial septal defect, etc.).Pre-organ transplant (non-cardiac). Some institutions perform a heart cath as part of their initial evaluation protocol. Others use an imaging stress test for evaluation. Either is appropriate and can be approved but NOT both.
® Valvular heart disease when either:
¡ there is a discrepancy between the clinical findings (history, physical exam, and non-invasive test results)
¡ Valvular surgery is being considered.
® Suspected pericardial disease.
® Previous cardiac transplant:
¡ Per transplant center protocol
¡ To assess for accelerated coronary artery disease associated with cardiac transplantation.

For this condition imaging is medically necessary based on the following criteria:

CD-7.4.1: General information RHC (CPT^® 93451)

† It is performed most commonly from the femoral vein, less often through the subclavian or internal jugular veins and inter-atrial septal puncture approach.

† It includes a full oximetry for detection and quantification of shunts.

† Pressure measurements are made and are done simultaneously with aortic and left ventricular pressures.

† Cardiac outputs are calculated by several techniques including thermodilution.

CD-7.4.2: Diagnostic Right Heart Catheterization – Indications

† Diagnostic Right heart cath is indicated when results will impact the diagnosis and management of any of the following:

® Atrial septal defect (ASD) including shunt detection and quantification
® Ventricular septal defect (VSD) including shunt detection and quantification
® Patent foramen ovale (PFO)
® Anomalous pulmonary venous return
® Congenital defects including persistent left vena cava
® Pulmonary hypertension
® Pericardial diseases (constrictive or restrictive pericarditis)
® Valvular disease
® Right heart failure
® Left heart failure
® Preoperative evaluation for valve surgery
® Newly diagnosed or worsening cardiomyopathy
® During a left heart cath where the etiology of the symptoms remains unclear.
® Pre-lung transplant to assess pulmonary pressures
® Uncertain intravascular volume status with an unclear etiology
® Assessment post-cardiac transplant
¡ For routine endomyocardial biopsy
¡ Assess for rejection
¡ Assess pulmonary artery pressure
¡ Can be done per the institution protocol or anytime organ rejection is suspected and biopsy is needed for assessment
® Evaluation of right ventricular morphology.
® Suspected arrhythmogenic right ventricular dysplasia.

For this condition imaging is medically necessary based on the following criteria:

† Preoperative evaluation for valve surgery

† The indications for CD-7.3: Diagnostic Left Heart Catheterization are met and any of the following are present:

® The major component of the member symptoms is dyspnea
® The indications are met according to CD-7.4: Right Heart Catheterization
® Newly diagnosed or worsening cardiomyopathy

For this condition imaging is medically necessary based on the following criteria:

† The CPT^® codes for percutaneous coronary interventions (PCI) include the following imaging services necessary for the procedure(s):

® Contrast injection, angiography, ‘road-mapping’, and fluoroscopic guidance
® Vessel measurement
® Angiography following coronary angioplasty, stent placement, and atherectomy

† A repeat diagnostic left heart catheterization is not medically necessary when the member is undergoing a planned staged percutaneous coronary intervention.

References
1. Boden WE, O'Rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. New England Journal of Medicine. 2007;356(15):1503-1516. doi:10.1056/nejmoa070829.
2. Friedewald VE, King SB, Pepine CJ, Vetrovec GW, Roberts WC. The Editor’s Roundtable: Chronic Stable Angina Pectoris. The American Journal of Cardiology. 2007;100(11):1635-1643. doi:10.1016/j.amjcard.2007.09.001.
3. Olade RB. Cardiac Catheterization of Left Heart: Background, Indications, Contraindications. TheHeart.org. https://emedicine.medscape.com/article/1819224-overview. Published January 7, 2017. Accessed September 19, 2018..
4. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):2354-2394. doi:10.1161/cir.0000000000000133.
5. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016;134(10). doi:10.1161/cir.0000000000000404.
6. 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. Journal of the American College of Cardiology. 2012;60(24). doi:10.1016/j.jacc.2012.07.013
7. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 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. Circulation. 2014;130(19):1749-1767. doi:10.1161/cir.0000000000000095.


CD-8: Pulmonary Artery and Vein Imaging

CD-8.1: Pulmonary Artery Hypertension (PAH) - Indications

CD-8.2: Pulmonary Vein Imaging - Indications

CD-8.1: Pulmonary Artery Hypertension (PAH) – Indications

For this condition imaging is medically necessary based on the following criteria:

† CT or CTA or MRA of the pulmonary arteries (CPT^® 71260 or CPT^® 71275 or CPT^® 71555) is useful in the assessment of PAH, especially if there is suspicion for recurrent pulmonary emboli.

† In the absence of a clinical change, follow-up imaging for PAH is not indicated.

† Also see:

® Adult Peripheral Vascular Disease Imaging Policy (Policy #158 in the Radiology Section); PVD-5: Pulmonary Artery Hypertension.
® Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-25: Pulmonary Embolism (PE).

For this condition imaging is medically necessary based on the following criteria:

† Cardiac MRI (CPT^® 75557 or CPT^® 75561 ), Chest MRV (CPT^® 71555), Chest CTV (CPT^® 71275), or Cardiac CT (CPT^® 75572) can be performed to evaluate the anatomy of the pulmonary veins:

® Prior to an ablation procedure performed for atrial fibrillation.
® Post-procedure between 3-6 months after ablation because of a 1% to 2% incidence of asymptomatic pulmonary vein stenosis.
¡ If no pulmonary vein stenosis is present, no further follow-up imaging is required.
¡ If pulmonary vein stenosis is present on imaging following ablation and symptoms of pulmonary vein stenosis (usually shortness of breath) are present, can be imaged at 1, 3, 6, and 12 months.
® The majority (81%) of pulmonary vein stenosis remain stable over 1 year. Progression occurs in 8.8% and regression occurs in a small percentage.

CD-9: Congestive Heart Failure

CD-9.1: CHF – Imaging

CD-9.2: Palliative Care in patients with heart failure

CD-9.3: Myocardial Sympathetic Innervation Imaging

For this condition imaging is medically necessary based on the following criteria:

† Congestive heart failure, including post-cardiac transplant failure:

® An echocardiogram is generally the first study to be done after the clinical evaluation of the member who is suspected of having heart failure.
® If the ECHO is limited or does not completely answer the question, then further evaluation with MUGA, cardiac MRI or cardiac CT may be appropriate.
® A stress test to assess for CAD may be appropriate. Follow stress testing guideline: CD-1.4: Stress Testing with Imaging – Indications

® CT Chest with contrast (CPT^® 71260 ) and/or CT Abdomen and/or CT Pelvis with contrast (CPT^® 74160 or CPT^® 72193 or CPT^® 74177) OR
® CTA Chest (CPT^® 71275 ) and/or CTA Abdomen and/or CTA Pelvis (CPT^® 74175 or CPT^® 72191 or CPT^® 74174) OR
® MRI Chest and/or MRI Abdomen and/or MRI Pelvis without and with contrast (CPT^® 71552 and/or CPT^® 74183 and/or CPT^® 72197) OR
® MRA Chest and/or MRI Abdomen and/or MRI Pelvis (CPT^® 71555 and/or CPT^® 74185 and/or CPT^® 72198)

® Chest CT (CPT^® 71260) or chest CTA (CPT^® 71275) to evaluate for recurrent pulmonary embolism

For this condition imaging is medically necessary based on the following criteria:

† There are currently no widely accepted published guidelines regarding end of life care for end-stage heart failure members who are not candidates for advanced heart failure treatments such as left ventricular assist devices, heart pumps or heart transplantation. Consideration for palliative care services should be given to such members.

CD-9.3: Myocardial Sympathetic Innervation Imaging

For this condition imaging is medically necessary based on the following criteria:

† In heart failure, the sympathetic nervous system is activated in order to compensate for the decreased myocardial function. Initially, this is beneficial, however, long-term this compensatory mechanism is detrimental and causes further damage.

† Markers have been developed, using radioactive iodine, in an attempt to image this increased myocardial sympathetic activity. Currently, AdreView^™ (Iodine-123 meta-iodobenzylguanidine), is the only FDA-approved imaging agent available for this purpose. eviCore currently considers AdreView™ to be investigational.

† The AMA has established the following set of Category III codes to report these studies:

® 0331T - Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment
® 0332T - Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment, with tomographic SPECT..

For this condition imaging is medically necessary based on the following criteria:

† Any of the following can be used to evaluate cardiac or aortic trauma:

® Echocardiogram (TTE, TEE)
® Cardiac MRI (CPT^® 75557, CPT^® 75561, and CPT^® 75565)
® Cardiac CT (CPT^® 75572)
® CCTA (CPT^® 75574)
® Chest CTA (CPT^® 71275)

CD-11: Adult Congenital Heart Disease

CD-11.1: Congenital heart disease – General Information

CD-11.1.1: Definitions

CD-11.1.2: Modalities

CD-11.1.3: Coding

CD-11.2: Congenital Heart Disease Imaging Indications

CD-11.2.1: ASD-Atrial septal defects

CD-11.2.2: Anomalous Pulmonary Venous Connections

CD-11.2.3: Ventricular Septal Defect (VSD)

CD-11.2.4: Atrioventricular Septal Defect (AV Canal, AVSD, endocardial cushion defect)

CD-11.2.5: Patent Ductus Arteriosus (PDA)

CD-11.2.6: Cor Triatriatum

CD-11.2.7: Congenital Mitral Stenosis

CD-11.2.8: Subaortic Stenosis (SAS)

CD-11.2.9: Congenital Valvular Aortic Stenosis

CD-11.2.10: Aortic disease in Turner Syndrome

CD-11.3: Aortopathies with CHF

CD-11.3.1: Supravalvular Aortic Stenosis

CD-11.3.2: Coarctation of the Aorta

CD-11.3.3: Valvular Pulmonary Stenosis

CD-11.3.4: Branch and Peripheral pulmonary stenosis

CD-11.3.5: Double chambered RV

CD-11.3.6: Ebstein Anomaly

CD-11.3.7: Tetralogy of Fallot (TOF, VSD with PS)

CD-11.3.8: Right Ventricle-to-Pulmonary Artery Conduit

CD-11.3.9: Transposition of the great arteries (TGA)

CD-11.3.10: Congenitally corrected TGA

CD-11.3.11: Fontan Palliation of Single Ventricle Physiology

CD-11.3.12: Severe Pulmonary artery hypertension (PHT) and Eisenmenger syndrome

CD-11.3.13: Coronary artery anomalies

CD-11.4: Pregnancy – Maternal Imaging

For this condition imaging is medically necessary based on the following criteria:

† This section covers adult congenital heart disease (CHD), for other associated disorders please see the condition specific sections

® Marfan Syndrome
® Hypertrophic cardiomyopathy (HCM)
® Bicuspid aortic valve (BAV)

† Physiological stages (A, B, C, D)

® Each congenital heart lesion is divided into 4 physiological stages (A, B, C, D)

Characteristics	Physiological stage
	A	B	C	D
NYHA functional class	I	II	III	IV
Hemodynamic or anatomic sequelae	None	Mild ventricular enlargement of dysfunction, small shunt	Moderate or greater, ventricular dysfunction. Any venous or arterial stenosis	Moderate or greater, ventricular dysfunction. Any venous or arterial stenosis
Valvar	None	Mild	Moderate or greater	Moderate or greater
Aortic enlargement	None	Mild	Moderate	Severe
Exercise capacity limitation	Normal	Abnormal objective cardiac limitation	Moderate	Severe
Renal hepatic pulmonary dysfunction	None		Mild but responsive to medication	Refractory to treatment
Cyanosis/ hypoxemia	None		Mild	Severe
Arrhythmias	None	Arrhythmia not requiring treatment	Needs rx	Refractory to rx
Pulmonary hypertension	None		Mild to moderate	Severe or Eisenmenger

® Class I-Simple
¡ Native disease
§ Isolated small ASD
§ Isolated small VSD
§ Mild isolated pulmonic stenosis
¡ Repaired conditions
§ Previously ligated or occluded ductus arteriosus
§ Repaired secundum ASD or sinus venosus defect without significant residual shunt or chamber enlargement
§ Repaired VSD without significant residual shunt or chamber enlargement
® Class II-Moderate Complexity
¡ Repaired or unrepaired conditions
§ Aorto-left ventricular fistula
§ Anomalous pulmonary venous connection, partial or total
§ Anomalous coronary artery arising from the pulmonary artery
§ Anomalous aortic origin of a coronary artery from the opposite sinus
§ AVSD (partial or complete, including primum ASD)
§ Congenital aortic valve disease
§ Congenital mitral valve disease
§ Coarctation of the aorta
§ Ebstein anomaly (disease spectrum includes mild, moderate, and severe variations)
§ Infundibular right ventricular outflow obstruction
§ Ostium primum ASD
§ Moderate and large unrepaired secundum ASD
§ Moderate and large persistently patent ductus arteriosus
§ Pulmonary valve regurgitation (moderate or greater)
§ Pulmonary valve stenosis (moderate or greater)
§ Peripheral pulmonary stenosis
§ Sinus of Valsalva fistula/aneurysm
§ Sinus venosus defect
§ Subvalvar aortic stenosis (excluding HCM; HCM not addressed in these guidelines)
§ Supravalvar aortic stenosis
§ Straddling atrioventricular valve
§ Repaired tetralogy of Fallot
§ VSD with associated abnormality and/or moderate or greater shunt
® Class III- Great Complexity (or Complex)
¡ Cyanotic congenital heart defect (unrepaired or palliated, all forms)
¡ Double-outlet ventricle
¡ Fontan procedure
¡ Interrupted aortic arch
¡ Mitral atresia
¡ Single ventricle (including double inlet left ventricle, tricuspid atresia, hypoplastic left heart, any other anatomic abnormality with a functionally single ventricle)
¡ Pulmonary atresia (all forms)
¡ TGA (classic or d-TGA; CCTGA or l-TGA)
¡ Truncus arteriosus
¡ Other abnormalities of atrioventricular and ventriculoarterial connection (i.e., crisscross heart, isomerism, heterotaxy syndromes, ventricular inversion)

† Echocardiogram- transthoracic (TTE) or transesophageal (TEE)

® Transthoracic echocardiography (TTE) is an indispensable tool in the initial and serial follow-up evaluation to identify abnormalities and changes that commonly influence management decisions.

® CMR plays a valuable role in assessment of RV size and function, because it provides data that are reproducible and more reliable than data obtained with alternative imaging techniques
® For intracardiac congenital heart disease, CMR will typically include flow velocity mapping for shunts and flow assessment.
® Imaging that only requires aortic arch imaging, does not require intracardiac CMR, only chest MRA.

® The most important disadvantage of CCT (including CT angiography) as an imaging technique is the associated exposure to ionizing radiation.

® (hemodynamic and/or angiographic) in members with adult CHD AP classification II and III, or interventional cardiac catheterization in members with adult CHD AP classification I to III should be performed by, or in collaboration with, cardiologists with expertise in adult CHD

® Exercise test does not imply stress imaging

® Includes-MPI, stress echo, stress MRI
® PET stress may be included as per CD-6

® Assessment of RV size and function in repaired Tetralogy of Fallot (TOF), systemic right ventricles, and other conditions associated with right ventricular (RV) volume and pressure overload
® Identification of anomalous pulmonary venous connections
® Serial assessment of thoracic aortic aneurysms, especially when the dilation might extend beyond the echocardiographic windows
® Accurate assessment of pulmonary artery (PA) pressure and pulmonary vascular resistance
® Assessment for re-coarctation of the aorta
® Sinus venosus defects
® Vascular rings
® Evaluation of coronary anomalies
® Quantification of valvular regurgitation

Modality	CPT®
Echocardiogram
Transthoracic echocardiogram (TTE)
TTE for congenital cardiac anomalies; complete	93303
TTE for congenital cardiac anomalies; limited study	93304
TTE (2D) m-mode recording, complete, with spectral and color flow doppler echocardiography	93306
TTE (2D) with or without m-mode recording; complete	93307
TTE (2D) with or without m-mode recording; limited study	93308
Transesophageal echocardiogram (TEE)
TEE (2D) including probe placement, imaging, interpretation, and report	93312
TEE for congenital cardiac anomalies; including probe placement, imaging, interpretation, and report	93315
MRI
cardiac (CMR)
Cardiac MRI for morphology and function without contrast	75557
Cardiac MRI for morphology and function without and with contrast	75561
Chest MRI
MRI chest without contrast	71550
MRI chest with contrast	71551
MRI chest with & without contrast	71552
MRI Angiography (MRA) Chest MRA
MRA chest (excluding myocardium) with or without contrast	71555
CT
cardiac (CCT)
CT, heart, with contrast material, for evaluation of cardiac structure and morphology	75572
CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease	75573
CT Angiography-cardiac (CCTA)
CTA heart, coronary arteries and bypass grafts (when present), with contrast, including 3D image post processing	75574
CT-chest
CT Thorax without contrast	71250
CT Thorax with contrast	71260
CT Thorax without & with contrast	71270
CT Angiography-chest (chest CTA)
CTA Chest without and with contrast	71275
Stress Imaging (echo, MRI, MPI)
Stress echo
Echocardiography (TTE), (2D), with or without m-mode, during rest and cardiovascular stress, with interpretation and report	93350
Echocardiography (TTE), (2D), m-mode, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation	93351
Stress MRI
Cardiac MRI for morphology and function without contrast, with stress imaging	75559
Cardiac MRI for morphology and function without and with contrast, with stress imaging	75563
Myocardial perfusion imaging (MPI)
MPI, 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)	78451
MPI, 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	78452
Pulmonary perfusion imaging
Pulmonary perfusion imaging (e.g., particulate)	78580
Pulmonary ventilation (e.g., aerosol or gas) and perfusion imaging	78582
Quantitative differential pulmonary perfusion, including imaging when performed	78597
Quantitative differential pulmonary perfusion and ventilation (e.g., aerosol or gas), including imaging when performed	78598

For this condition imaging is medically necessary based on the following criteria:

† The following sections are based on the congenital heart lesion. Requests for imaging based on other cardiac conditions, such as CAD, HCM, acquired valvular lesions, should follow the adult cardiac guidelines for those conditions.

CD-11.2.1: ASD-Atrial septal defects

† This section does not include patent foramen ovale (PFO) or PFO occluders.

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram at time of diagnosis
¡ CMR, CCT (75573), and/or TEE are useful if echo (TTE) is suboptimal and either:
§ ASD is suspected
§ To evaluate pulmonary venous connections in known ASD
¡ Chest MRA or chest CTA may be indicated if echo shows pulmonary venous anomalies
§ If normal then repeat pulmonary vein imaging is not required.
® Transesophageal echocardiogram (TEE) is recommended to guide percutaneous ASD closure
® Diagnostic cath is indicated when there is either:
¡ Evidence of pulmonary hypertension
¡ Unanswered questions on CMR/CCT for venous drainage.

® 6 months to evaluate for erosion
® 1 week (if amplazter)
® 1 month
® 6 months
® 12 months
® then every 1-2 years

† Stress imaging and coronary artery imaging would be based on CD-1.4: Stress Testing with Imaging – Indications

Follow-up ASD. SD, if surgically closed or if no interventions

Modality	Physiological stage / intervals for routine imaging (months)
Physiological stage	A	B	C	D
TTE	36-60	24	12	12

CD-11.2.2: Anomalous Pulmonary Venous Connections

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram at time of diagnosis
¡ CMR and/or Chest MRA, or cardiac CT and/or chest CTA at time of diagnosis if any issues with pulmonary veins or RV volume.
¡ Cardiac Cath at time of diagnosis for hemodynamic data and issues not answered on other imaging
® Routine stress imaging or coronary artery imaging not required.
® Echo, CMR, CT, per cardiology request for clinical changes
¡ Diagnostic heart catheterization if questions unanswered on imaging

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echo (TTE) at time of diagnosis
¡ CMR or CCT can be performed if questions are unanswered on echo
¡ Catheterization at time of diagnosis for hemodynamics if pulmonary hypertension (PHT) or shunt size is a question

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echo (TTE) at time of diagnosis
¡ CMR or cardiac CT at time of diagnosis if there are unanswered questions on echo
¡ Cardiac cath at time of diagnosis when CMR and TTE leave questions unanswered that affect member management
® Stress imaging per CD-1.4: Stress Testing with Imaging – Indications

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echo at time of diagnosis
¡ Chest MR or Chest CT if there are questions left unanswered by echo
¡ Cardiac Cath for hemodynamics (if planned device closure, diagnostic cardiac cath is not indicated as it is included in the procedure code)
® Stress imaging per CD-1.4: Stress Testing with Imaging – Indications

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
¡ CMR and/or Chest MRA or cardiac CT and/or chest CTA may be approved
¡ Diagnostic cath may be approved if additional information is required for medical management
® Long term follow-up
¡ Stress imaging per CD-1.4: Stress Testing with Imaging – Indications

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
® Stress imaging (stress echo or stress MRI) for any of the following:
¡ Once at the time of diagnosis
¡ New or changed signs or symptoms of ischemia
¡ Changes in cardiac function
¡ If cardiac intervention is being considered
¡ Any signs or symptoms allowed in CD-1.4: Stress Testing with Imaging – Indications

Modality	Physiological stage / intervals for routine imaging (months)
Physiological stage	A	B	C	D
Echo (TTE)	24	24	12	12
Stress imaging		24	24	12

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
® TEE may be required if TTE limited or equivocal
® Chest MRA or chest CTA if one of the following:
¡ Suspicion of Coarctation based on exam and echocardiogram
¡ Proximal ascending aorta not well visualized on TTE

Modality	Physiological stage / intervals for routine imaging
Stage (valvular AS)	Progressive (stage B) Mild Vmax 2.0-2.9 m/s	Progressive (stage B) Moderate Vmax 3.0-3.9 m/s	Severe (stage C) >4.0 m/s	Aortic root dilation >4.5 cm
echo (TTE)	3-5 years	1-2 years	6-12 months	12 months
Chest MRA or CTA				if ascending allowed yearly

	Mild AS	Moderate AS	Severe AS
Vmax(ms/s)2	2.0-2.9	3.0-3.9	≥ 4.0
Mean gradient (mmHg)a	<30	30-49	≥ 50
AVA (cm2)	>1.5	1.0-1.5	<1.0
AVAi (cm2/m2 BSA)	≥ 1.0	0.6-0.9	<0.6

CD-11.2.10: Aortic disease in Turner Syndrome

† Dissection more common for a given aortic diameter. Mid-ascending aortic disease more common and my not be reliably seen on echocardiogram

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
® Chest MRA or chest CTA to rule out mid ascending aortic aneurysm if mid aorta was not seen on echocardiogram.

® Echocardiogram (TTE) yearly
¡ Chest MRA or CTA if mid ascending aorta not visualized
® For documented thoracic aortic aneurysm (TAA) ≤ 4cm
¡ Routine Chest MRA or CTA yearly
® For documented thoracic aortic aneurysm (TAA) ˃ 4cm
¡ Chest MRA or CTA every 6 months.

For this condition imaging is medically necessary based on the following criteria:

† Dilated aortic arches are not uncommon with several congenital heart disease and postoperative procedures including- Aortic stenosis, Ross repair, Tetraology of Fallot, Transposition of the great arteries (TGA), Pulmonary atresia, hypoplastic left heart syndrome (HLHS), Truncus Arteriosis, single ventricle members.

CD-11.3.1: Supravalvular Aortic Stenosis

† Supravalvular aortic stenosis is a relatively rare condition overall but is seen commonly in members with Williams syndrome or homozygous familial hypercholesterolemia.

† Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
® Chest MRA or chest CTA

® Cardiac MRI or cardiac CTA to assess coronary ostea
® Cardiac cath for any members pre cardiac intervention for coronary arteries

® Cardiac CT or cardiac MR
® Chest CTA or chest MRA
® Stress imaging as per CD-1.4: Stress Testing with Imaging – Indications

† Coarctation is suspected based on clinical findings:

® BP higher in upper extremities than in the lower extremities
® Absent femoral pulses
® Continuous murmur
® Abdominal bruit
® Berry aneurysm with hemorrhage
® Rib notching on x-ray
® Abnormal thoracic aortic imaging and blood pressures

® Echocardiogram (TTE) at time of diagnosis
¡ No further imaging is required if echocardiogram (TTE), blood pressure, and exam rule out Coarctation.
¡ Echo and exam are equivocal or positive one of the following is indicated:
§ Chest CTA
§ Chest MRA
¡ Members with Coarctation of the aorta do not require intracardiac MR unless issue cannot be resolved on echocardiogram.
¡ Screening for intracranial aneurysm by MRA or CTA of head is allowed
® ETT for diagnosis of exercise induced hypertension does not require imaging
® Cardiac MR not required unless issues unresolved by echo for intracardiac anatomy
® Diagnostic cath can be approved prior to stenting of PDA
® Stress imaging, TEE, Cardiac MR or CT, Coronary imaging not routinely

® Members with Coarctation are at risk for dissection. When member has new or worsening symptoms any of the following:
¡ Echocardiogram (TTE)
¡ Chest MRA or CTA.
® For exertional symptoms, one of the following:

¡ Stress imaging-per CD-1.4: Stress Testing with Imaging – Indications
¡ Cardiac MRI or cardiac CT

† Overview Initial studies-Diagnosis, clinical changes, consideration of surgery

® Echocardiogram (TTE) at time of diagnosis
® For issues affecting management not well visualized on TTE
¡ Cardiac MRI or cardiac CT
¡ Chest MRA or chest CTA

® Echocardiogram-stages
¡ Mild PS – peak gradient <36 mmHg (peak velocity < 3m/s)
¡ Moderate PS- peak gradient 36-64 mmHg (peak velocity 3-4 m/s)
¡ Severe PS- peak gradient >64 mmHg (peak velocity > 4 m/s); or mean gradient >35 mmHg.
® Routine stress imaging is not required
® Routine chest or cardiac or ischemia workup not required.

† Overview

® Can be seen in newborns as a normal variant in the first 6 months of life
® Can be seen in surgeries of right ventricular outflow (TOF)
¡ Noonan
¡ Alagille
¡ Williams
¡ Maternal rubella exposure
¡ Keutel syndrome