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.

Policy
All criteria are substantiated by the latest evidence-based medical literature. To enhance transparency and reference, Appropriate Use (AUC) scores, when available, are diligently listed alongside the criteria.
This guideline first defaults to AUC scores established by published, evidence-based guidance endorsed by professional medical organizations. In the absence of those scores, we adhere to a standardized practice of assigning an AUC score of 6. This score is determined by considering variables that ensure the delivery of patient-centered care in line with current guidelines, with a focus on achieving benefits that outweigh associated risks.
This approach aims to maintain a robust foundation for decision-making and underscores our commitment to upholding the highest standards of care. (4,5,6,7,8)

INDICATIONS FOR HEART PET WITH CT FOR ATTENUATION (9,10,11)
Suspected CAD
When neither SE nor MPI have provided or are expected to provide optimal imaging
●  

• Symptomatic patients without known CAD. No imaging stress test within the last 12 months. The terms "typical," "atypical," and "non-anginal symptoms" can still be observed in medical records (consult the Diamond Forrester table in the Definitions section). However, the ACC has simplified its terminology to "Less likely anginal symptoms" and "Likely anginal symptoms" (refer to Definitionssection) and utilized below.
  • Less-likely anginal symptoms (AUC 4-6)
    • When a patient cannot walk a treadmill
    • When baseline EKG makes standard exercise test inaccurate (see Definitions section).
    • When a noncardiac explanation is provided for symptoms, no testing is required (AUC 8)
  • Likely Anginal Symptoms (typical angina)
    • < 50 years old with ≤ one risk factor if an ECG treadmill test cannot be done. **AUC scores for this bullet point are identical for MPI, stress echo, and ETT (AUC 7). Although the ACC guideline does not specify youth and gender, decisions should be guided by best medical judgment, considering factors such as safety and radiation exposure.
    • ≥ 50 years old (AUC 8)
  • Repeat testing in a patient with new or worsening symptoms and negative result at least one year ago AND meets one of the criteria above
• Asymptomatic patients without known CAD
  • Previously unevaluated ECG evidence of possible myocardial ischemia including substantial ischemic ST segment or T wave abnormalities (see Background section)
  • Previously unevaluated pathologic Q waves (see Background section)
  • Unevaluated complete left bundle branch block (AUC8) ⁽³⁾

Abnormal Calcium Scores (CAC) (9,12,13,14,15)
When neither SE nor MPI have provided, or are expected to provide, optimal imaging

• ASYMPTOMATIC high global CAD risk patient with a prior Coronary Calcium Agatston Score of > 100. No prior MPI done within the last 12 months ⁽¹⁶⁾
• Asymptomatic patient with Coronary Calcium Agatston Score > 400. No prior MPI done within the last 12 months

Inconclusive CAD Evaluation and Obstructive CAD remain a Concern
When neither SE nor MPI have provided, or are expected to provide, optimal imaging

• Exercise stress ECG with low-risk Duke treadmill score (≥ 5) (see Background section) but patient’s current symptoms indicate increasing likelihood of disease
• Exercise stress ECG with an intermediate Duke treadmill score (AUC8)⁽³⁾
• Inconclusive/borderline coronary computed tomography angiography (CCTA) or SPECT nuclear stress testing (e.g., 40 - 70% lesions) (AUC 9) ⁽³⁾
• Cardiac PET stress-rest perfusion and metabolic activity study (with ¹⁸F-FDG PET) is appropriate in patients with ischemic cardiomyopathy to determine myocardial viability prior to revascularization following an inconclusive SPECT ^(9,17) (AUC 9) ⁽³⁾
• Non-diagnostic exercise stress test with physical inability to achieve target heart rate (THR)
• An intermediate evaluation by prior stress imaging
• Coronary stenosis of unclear significance on previous coronary angiography ⁽⁹⁾ (AUC 8) (3)

Follow-Up Of Patient’s Post Coronary Revascularization (PCI or CABG)
When neither SE nor MPI have provided, or are expected to provide, optimal imaging (9)

• For patients with high occupational risk (e.g., associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers, and firefighters)

New, recurrent, or worsening symptoms post coronary revascularization treated medically or by revascularization is an indication for stress imaging, if it will alter management for typical anginal symptoms or symptoms documented to be similar to those prior to revascularization if no imaging stress test within the last 12 months. (AUC 8)

Follow-Up Of Known CAD (9)
When neither SE nor MPI have provided, or are expected to provide, optimal imaging

• Follow-up of asymptomatic or stable symptoms when last invasive or non- invasive assessment of coronary disease showed hemodynamically significant CAD (ischemia on stress test or FFR ≤ 0.80 or significant stenosis in a major vessel (≥ 50% left main coronary artery or ≥ 70% LAD, LCX or RCA)), over two years ago, without intervening coronary revascularization is an appropriate indication for stress imaging in patients if it will alter management

Special Diagnostic Conditions Requiring Coronary Evaluation
When neither SE nor MPI have provided, or are expected to provide, optimal imaging

• Radiation
  • Following radiation therapy to the anterior or left chest, at 5 years post initiation and every 5 years thereafter (²⁷⁾
• Cardiac Sarcoidosis ^(28,29,30)
  • May be approved as a combination study with MPI for the evaluation and treatment of sarcoidosis. ⁽³¹⁾
    • Evaluation and therapy monitoring in patients with sarcoidosis, after documentation of suspected cardiac involvement by echo or ECG, when CMR has not been performed
    • Evaluation of suspected cardiac sarcoid, after CMR has shown equivocal or negative findings in the setting of a high clinical suspicion (30)
  • Evaluation of CMR findings showing highly probable cardiac sarcoidosis, when PET could serve to identify inflammation and the consequent potential role for immunosuppressive therapy ⁽³⁰⁾ (AUC 9) ⁽³⁾
  • Initial and follow-up PET in monitoring therapy for cardiac sarcoid with immunosuppressive therapy, typically about 4 times over 2 years
• Infective Endocarditis
  • In suspected infective endocarditis with moderate to high probability (i.e., staph bacteremia, fungemia, prosthetic heart valve, or intracardiac device), when TTE and TEE have been inconclusive with respect to diagnosis of infective endocarditis or characterization of paravalvular invasive complications ^(32,33,34)
• Aortitis
  • For diagnosis and surveillance of Aortitis, PET/CT or PET/MRI^‡ hybrid imaging (35)
• ^‡NOTE: If PET/MR study is requested, there is no specific CPT Code for this imaging study and a Health Plan review will be required.

Prior To Elective Non-Cardiac Surgery
When neither SE nor MPI have provided or are expected to provide optimal imaging

• Surgical Risk:
  • High risk surgery: Aortic and other major vascular surgery, peripheral vascular surgery, anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
  • Intermediate risk surgery: Carotid endarterectomy, head and neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, prostate surgery
  • Lowrisksurgery: Endoscopic procedures, superficial procedure, cataract surgery, breast surgery
• Planning for any organ or stem cell transplantation is an indication for preoperative stress imaging, if there has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year, at the discretion of the transplant service ⁽³⁹⁾

Post Cardiac Transplant
SE diversion not required (40)

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

Rationale
A PET study is a diagnostic test used to evaluate blood flow to the heart. During the test, a small amount of radioactive tracer is injected into a vein. A special camera, called a gamma camera, detects the radiation released by the tracer to produce computer images of the heart. Combined with a medication, the test can help determine if there is adequate blood flow to the heart during activity versus at rest. The medication simulates exercise for patients unable to exercise on a treadmill or stationary cycle.

PET prefusion studies illustrate myocardial blood flow by demonstrating tracer uptake. PET metabolic evaluation studies are used to demonstrate inflammation produced by infiltrative disease such as sarcoidosis, but also enhance the detection of viable (hibernating) myocardium. Hybrid PET-CT scanning combines anatomical information with blood flow assessment and is useful for assessing viable myocardium, especially in CHF patients with global ischemia, or in patients with multivessel diffuse coronary artery disease as opposed to focal stenotic lesions.

AUC Score
A reasonable diagnostic or therapeutic procedure care can be defined as that for which the expected clinical benefits outweigh the associated risks, enhancing patient care and health outcomes in a cost-effective manner. (4)

• Appropriate Care - Median Score 7-9
• May be Appropriate Care - Median Score 4-6
• Rarely Appropriate Care - Median Score 1-3

Definitions

• Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Websites for Global Cardiovascular Risk Calculators section).
• Symptomatic, for whom we estimate the pretest probability that their chest-

related symptoms are due to clinically significant (≥ 50%) CAD (below)

• The medical record should provide enough detail to establish the type of chest pain:
  • Likely Anginal symptoms encompass chest/epigastric/shoulder/arm/jaw pain, chest pressure/discomfort occurring with exertion or emotional stress and relieved by rest, nitroglycerine or both.
  • Less-Likely Anginal symptoms include dyspnea, or fatigue not relieved by rest/nitroglycerin, as well as generalized fatigue or chest discomfort with a time course not indicative of angina (e.g., resolving spontaneously within seconds or lasting for an extended period unrelated to exertion).
• Risk Factors for Coronary disease include (but not limited to): diabetes mellitus, smoking, family history of premature CAD (men age less than 55, females less than 65), hypertension, dyslipidemia.
• Beginning 2023, the classification terms for angina were updated within the ACC’s Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease to Less Likely Anginal Symptoms and Likely Anginal Symptoms. Previously, the document referred to “Typical Angina”, “Atypical Angina” and “Non-Anginal” symptoms, defined by the Diamond Forrester Table. We still provide this information for your reference ^(9,10,11):