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

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

Abbreviations

Policy
 

GENERAL INFORMATION

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

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Multiple Gates Acquisition (MUGA) Scan are considered medically necessary for the following indications:

Indications for Multiple Gated Acquisition (MUGA) Scan¹

• To evaluate left ventricular function in a patient with coronary artery disease, valvular heart disease, myocardial disease, or congenital heart disease, in any of the following scenarios:
  • When ventricular function is required for management, and transthoracic echocardiography (TTE) or other imaging has proven inadequate^2,3
  • When there are conflicting results between other testing (i.e., Myocardial Perfusion Imaging and TTE) in the measurement of ejection fraction (EF), and the results of the MUGA will help in the management of the patient
  • Prior TTE has demonstrated systolic dysfunction (EF < 50%) and management will change based on the results of the MUGA scan
• In the course of treatment with cardiotoxic medication when TTE images are inadequate to evaluate left ventricular systolic function^2,3,4,5,6:
  • Baseline assessment prior to initiation of therapy.
  • Monitoring during therapy. The frequency of testing should be left to the discretion of the ordering provider but in the absence of new abnormal findings, generally no more often than every 6 weeks while on active therapy.
  • Long term surveillance after completion of therapy may be required, especially for those who have been exposed to anthracycline medication. The frequency of testing is generally every 6 – 12 months, or at the discretion of the provider.

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

References 

1. Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. J Am Coll Cardiol. Feb 5 2019;73(4):488-516. doi:10.1016/j.jacc.2018.10.038
2. Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol. May 28 2013;61(21):2207-31. doi:10.1016/j.jacc.2013.02.005
3. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. May 3 2022;145(18):e876-e894. doi:10.1161/cir.0000000000001062
4. Plana JC, Galderisi M, Barac A, et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. Sep 2014;27(9):911-39. doi:10.1016/j.echo.2014.07.012
5. Zamorano JL, Lancellotti P, Rodriguez Muñoz D, et al. 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. Sep 21 2016;37(36):2768-2801. doi:10.1093/eurheartj/ehw211
6. Baldassarre LA, Ganatra S, Lopez-Mattei J, et al. Advances in Multimodality Imaging in Cardio-Oncology: JACC State-of-the-Art Review. J Am Coll Cardiol. Oct 18 2022;80(16):1560- 1578. doi:10.1016/j.jacc.2022.08.743
7. Friedman JD, Berman DS, Borges-Neto S, et al. First-pass radionuclide angiography. J Nucl Cardiol. Nov 2006;13(6):e42-55. doi:10.1016/j.nuclcard.2006.08.006
8. Mitra D, Basu S. Equilibrium radionuclide angiocardiography: Its usefulness in current practice and potential future applications. World J Radiol. Oct 28 2012;4(10):421-30. doi:10.4329/wjr.v4.i10.421
9. Ritchie JL, Bateman TM, Bonow RO, et al. Guidelines for clinical use of cardiac radionuclide imaging. Report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Radionuclide Imaging), developed in collaboration with the American Society of Nuclear Cardiology. J Am Coll Cardiol. Feb 1995;25(2):521-47. doi:10.1016/0735-1097(95)90027-6

Coding Section 

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

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

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

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