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.

Policy
Medical necessity for myocardial perfusion imaging (MPI) will consider the preference for appropriate alternatives, such as stress echocardiography (SE), when deemed more suitable, unless contraindications are present (see DEFINITIONS section). 

INDICATIONS FOR MPI^6,7,8,9,10
Suspected Coronary Artery Disease (CAD)

• 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 definitions) 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 prior AND meets one of the criteria above. 
• Asymptomatic patients without known CAD AUC Score = 7
  • A pharmacologic MPI is indicated for those unable to exercise with previously unevaluated ECG evidence of possible myocardial ischemia including ischemic ST segment or T wave abnormalities (see DEFINITIONS section).
  • Previously unevaluated pathologic Q waves (see DEFINITIONS section)
  • Previously unevaluated complete left bundle branch block

Abnormal Calcium Scores^{9,11,12,13,14}
AUC Score = 7

• STABLE SYMPTOMS with a prior Coronary Calcium Agatston Score of > 100. No prior stress imaging done within the last 12 months⁶
• ASYMPTOMATIC high global CAD risk patient with a prior Coronary Calcium Agatston Score of > 100. No prior stress imaging done within the last 12 months⁶
• Asymptomatic patient with Coronary Calcium Agatston Score > 400. No prior stress imaging done within the last 12 months

Inconclusive CAD Evaluation and Obstructive CAD
REMAINS A CONCERN:

• Exercise stress ECG with low-risk Duke treadmill score (≥ 5), (see DEFINITIONS section) but patient’s current symptoms indicate increasing likelihood of disease AUC score = 8
• Exercise stress ECG with an intermediate Duke treadmill score (of note, SE diversion is not required for symptoms consistent with likely anginal symptoms)
• Intermediate coronary computed tomography angiography (CCTA) (40% – 70% lesions) performed less than 90 days ago. (AUC Score = 7)
• Non-diagnostic exercise stress test with inability to achieve target heart rate (THR) defined as greater than 85% age predicted maximal heart rate by physiologic exercise).AUC Score = 8
• An indeterminate (equivocal, borderline, or discordant) evaluation by prior stress imaging (SE or CMR) within the last 12 months
• Coronary stenosis of unclear significance on previous coronary angiography not previously evaluated⁹

Follow-Up of Patient's Post Coronary Revascularization (PCI or CABG)⁹

• Asymptomatic follow-up stress imaging at a minimum of 2 years post coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (whichever is later) is appropriate for patients with: (AUC = 6) (of note, SE diversion is not required for post CABG patients)
  • High risk: diabetes with accelerated progression of CAD, CKD, PAD, prior brachytherapy, ISR, or SVG intervention.
  • a history of silent ischemia or
  • a history of a prior left main stent

OR

• For patients with high occupational risk, associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers and firefighters (of note, SE diversion not required for post-CABG patients)
• New, recurrent, or worsening symptoms, 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 Score 8)⁶

Follow-Up of Known CAD

• Follow-up of asymptomatic or stable symptoms when last invasive or non-invasive assessment of coronary disease showed hemodynamically significant CAD (ischemia on stress test or FFR ≤ 0.80 or significant stenosis in a major vessel (≥50% left main coronary artery or ≥ 70 % LAD, LCX, 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
AUC Score = 8

Unevaluated ACS

• Prior acute coronary syndrome (with documentation in MD notes), without invasive or non-invasive coronary evaluation within last 12 months
• Has ventricular wall motion abnormality demonstrated by another imaging modality and myocardial perfusion imaging is being performed to determine if the patient has myocardial ischemia. No imaging stress test within the last 12 months

Heart Failure

• Newly diagnosed systolic heart failure or diastolic heart failure, with reasonable suspicion of cardiac ischemia (prior events, risk factors), unless invasive coronary angiography is immediately planned.^7,15,16,17 No imaging stress test done within the last 12 months.

Viability

• LVEF requiring myocardial viability assessment to assist with decisions regarding coronary revascularization (AUC Score 9)^6,9

Suboptimal Revascularization

• MPI is being done to evaluate the effectiveness of the intervention in a high-risk patient who has undergone cardiovascular re-perfusion (CABG or Percutaneous Coronary Intervention, PCI) with suboptimal and/or incomplete revascularization results. No imaging stress test has been done within the last 12 months. (AUC Score 7)^6,9

Arrhythmias

• Ventricular arrhythmias (AUC Score = 7)
  • Sustained ventricular tachycardia (VT) > 100 bpm, ventricular fibrillation (VF), or exercise-induced VT, when invasive coronary arteriography is not immediately planned¹⁸
  • Non-sustained VT, multiple episodes, each ≥ 3 beats at ≥ 100 bpm, or frequent PVCs (defined as greater than or equal to 30/hour on remote monitoring) without known cause or associated cardiac pathology, when an exercise ECG cannot be performed¹⁹

Anti-Arrhythmic Drug Therapy

• Class IC antiarrhythmic drug
  • In the intermediate and high global risk patient prior to initiation of Class IC antiarrhythmic drug initiation (Propafenone or Flecainide)
  • Annually in intermediate and high global risk patients taking Class IC antiarrhythmic drug (Propafenone or Flecainide)²⁰

Coronary Anomaly and Aneurism

• Assessment of hemodynamic significance of one of the following documented conditions:
  • Anomalous coronary arteries²¹
  • Myocardial bridging of coronary artery
• Coronary aneurysms in Kawasaki’s disease²² or due to atherosclerosis 

Radiation and Chemotherapy

• Following radiation therapy to the anterior or left chest, at 5 years post initiation and every 5 years thereafter²³

Sarcoidosis and Amyloidosis (PYP study)

• Cardiac sarcoidosis: as a combination study with Heart PET for the evaluation and treatment of cardiac sarcoidosis²⁴
• Cardiac amyloidosis: for the diagnosis of cardiac transthyretin amyloidosis (ATTR) 

*Not to be used for the diagnosis of cardiac light chain amyloidosis (AL)²⁵

Prior To Elective Non-Cardiac Surgery In Asymptomatic Patient
AUC score = 8

• An intermediate or high risk surgery with of one or more risk factors (see below), AND documentation of an inability to walk (or < 4 METs) AND there has not been an imaging stress test within 1 year^26,27,28
  • Risk factors: history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine > 2.0 mg/dL
  • 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
    • Low-risk surgery: Endoscopic procedures, superficial procedure, cataract surgery, breast surgery
• Planning for any organ or stem cell transplantation is an indication for preoperative MPI, if there has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year, at the discretion of the transplant service.^8,29

Post Cardiac Transplant (SE Diversion Not Required)

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

Rationale
Myocardial perfusion imaging is used primarily for the evaluation of coronary artery disease and determining prognosis. Myocardial perfusion imaging is a cardiac radionuclide imaging procedure that evaluates blood flow to the cardiac muscle during rest or stress. Stress may be provided by exercise or with pharmacologic agents. A variety of radionuclides may be used, including Technetium tc-99M sestamibi, thallium201 and Technetiumtc-99M tetrofosmin.

For those patients who are unable to complete the exercise protocol without achieving >85% of predicted maximal heart rate, a pharmacological nuclear stress test is recommended. This testing method uses a drug to mimic the response of the cardiovascular system to exercise. Adenosine, Persantine, Dobutamine, or Regadenoson are vasodilators used in pharmacological nuclear stress testing. A gamma camera is used to record images in planar or tomographic (single photon emission computed tomography, SPECT) projections.

High global CAD risk is defined as 10-year CAD risk of > 20%. CAD equivalents (e.g., DM, PAD) can also define high risk.
10 year CAD risk (%) is defined based on the risk factors- Sex, Age, Race, Total Cholesterol, HDL Cholesterol, Systolic Blood Pressure, and Treatment for High Blood Pressure, Diabetes Mellitus, and Smoker.

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.(3)

Appropriate Care — Median Score 7 – 9
May be Appropriate Care — Median Score 4 – 6
Rarely Appropriate Care — Median Score 1 – 3

Definitions

• Stable patients without known CAD fall into 2 categories:^7,8,9
  • 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 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 as in #2. 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:^7,8,9

Diamond Forrester Table (31,32)

Age (Years)	Gender	Typical/Definite Angina Pectoris	Atypical/Probable Angina Pectoris	Nonanginal Chest Pain
≤39	Men	Intermediate	Intermediate	Low
	Women	Intermediate	Very low	Very low
40-49	Men	High	Intermediate	Intermediate
	Women	Intermediate	Low	Very low
50-59	Men	High	Intermediate	Intermediate
	Women	Intermediate	Intermediate	Low
≥60	Men	High	Intermediate	Intermediate
	Women	High	Intermediate	Intermediate

• Very low: < 5%pretest probability of CAD, usually not requiring stress evaluation
• Low: 5% – 10% pretest probability of CAD
• Intermediate: 10% – 90% pretest probability of CAD
• High: > 90% pretest probability of CAD
• An uninterpretable baseline ECG includes:⁷
  • ST segment depression is considered significant when there is 1 mm or more, not for non-specific ST - T wave changes
  • Ischemic looking T waves are considered significant when there are at least 2.5 mm inversions (excluding V1 and V2)
  • Bundle Branch Blocks
  • LBBB
  • RBBB or IVCD, containing ST or T wave abnormalities
  • LVH with repolarization abnormalities
  • Ventricular paced rhythm
  • Digitalis use with associated ST segment abnormalities
  • Resting HR under 50 bpm on a medication, such as beta-blockers or calcium channel blockers, that is required for patient’s treatment and cannot be stopped, with an anticipated suboptimal workload
• Previously unevaluated pathologic Q waves (in two contiguous leads) defined as the following:
  • 40 ms (1 mm) wide
  • 2 mm deep
  • 25% of depth of QRS complex
• ECG stress test alone versus stress testing with imaging 

Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise:⁹

• The (symptomatic) low or intermediate pretest probability patient who can exercise and has an interpretable ECG⁹
• The patient who is under evaluation for exercise-induced arrhythmia
• The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
• For the evaluation of syncope or presyncope during exertion³³
  • When exercise cannot be performed, pharmacologic stress can be considered.
• Duke Exercise ECG Treadmill Score³⁴
  • Calculates risk from ECG treadmill alone:
    • The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 0 = none, 1 = non-limiting, and 2 = exercise-limiting
    • The score typically ranges from - 25 to + 15. These values correspond to low-risk (with a score of ≥ + 5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of ≤ - 11) categories
• MPI may be performed without diversion to a SE in any of the following:^9,35
  • Inability to Exercise
    • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
    • Limited functional capacity (< 4 METS) such as one of the following:
    • Unable to take care of their ADLs or ambulate
    • Unable to walk 2 blocks on level ground
    • Unable to climb 1 flight of stairs
  • Other Comorbidities
    • Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
    • Poorly controlled hypertension, with systolic BP > 180 or diastolic BP > 120 (and clinical urgency not to delay MPI)
  • ECG and Echo-Related Baseline Findings
    • Prior cardiac surgery (coronary artery bypass graft or valvular)
    • Documented poor acoustic imaging window
    • Left ventricular ejection fraction ≤ 40%
    • Pacemaker or ICD
    • Persistent atrial fibrillation
    • Resting wall motion abnormalities that would make SE interpretation difficult
    • Complete left bundle branch block (LBBB)
  • Risk-Related scenarios
    • High pretest probability in suspected CAD
    • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs (prior to initiation of therapy and annually)
    • Arrhythmia risk with exercise
    • Previously unevaluated pathologic Q waves (in two contiguous leads)
• Global Risk of Cardiovascular Disease
  • Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years.
    • CAD Risk — Low 
      • 10-year absolute coronary or cardiovascular risk less than 10%.
    • CAD Risk — Moderate 
      • 10-year absolute coronary or cardiovascular risk between 10% and 20%. 
    • CAD Risk — High  
      • 10-year absolute coronary or cardiovascular risk of greater than 20%.

Websites for Global Cardiovascular Risk Calculators* (36,37,38,39,40)

Risk Calculator	Websites for Online Calculator
Framingham Cardiovascular Risk	https://reference.medscape.com/calculator/framingham-cardiovascular-disease-risk
Reynolds Risk Score Can use if no diabetes Unique for use of family history	http://www.reynoldsriskscore.org/
Pooled Cohort Equation	http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx?example
ACC/AHA Risk Calculator	http://tools.acc.org/ASCVD-Risk-Estimator/
MESA Risk Calculator With addition of Coronary Artery Calcium Score, for CAD-only risk	https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx

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

• Definitions of Coronary Artery Disease^7,8,13,41

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

• Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. Its incorporation into global risk can be achieved by using the MESA risk calculator.
• Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
  • Suggested by percentage diameter stenosis ≥ 70% by angiography; intermediate lesions are 50% – 69%⁹
  • For a left main artery, suggested by a percentage stenosis ≥ 50%^7,41,42
  • FFR (fractional flow reserve) ≤ 0.80 for a major vessel^41,42
  • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
• FFR (fractional flow reserve) is the distal to proximal pressure ratio across a coronary lesion. Less than or equal to 0.80 is considered a significant reduction in coronary flow.

• Anginal Equivalent^7,33

Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons to suspect that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia). This may include respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope per se is not an anginal equivalent.

Abbreviations

ADLs	Activities of daily living
BSA	Body surface area in square meters
CABG	Coronary artery bypass grafting
CAD	Coronary artery disease
CMR	Cardiac magnetic resonance imaging
CTA	Computed tomography angiography
ECG	Electrocardiogram
FFR	Fractional flow reserve
IVUS	Intravascular ultrasound
LBBB	Left bundle-branch block
LVEF	Left ventricular ejection fraction
LVH	Left ventricular hypertrophy
MI	Myocardial infarction
MET	Estimated metabolic equivalent of exercise
MPI	Myocardial perfusion imaging
PCI	Percutaneous coronary intervention
PFT	Pulmonary function test
PVCs	Premature ventricular contractions
SE	Stress echocardiography
THR	Target heart rate
VT	Ventricular tachycardia
VF	Ventricular fibrillation
WPW	Wolf Parkinson White

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Coding Section 

Code	Number	Description
CPT	78451	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic
	78452	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
	78453	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
	78454	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
	78466	Myocardial imaging, infarct avid, planar; qualitative or quantitative
	78468	Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
	78469	Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification
	78481	Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
	78483	Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification
	78499	Unlisted cardiovascular procedure, diagnostic nuclear medicine
	0742T	Absolute quantitation of myocardial blood flow (AQMBF), single-photon emission computed tomography (SPECT), with exercise or pharmacologic stress, and at rest, when performed (List separately in addition to code for primary procedure)

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 nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

History From 2024 Forward     

12/02/2024	Annual review, policy updated for clarity and consistency including adding AUC scoring, anginal symptoms verbiage updated, new guidelines for stress testing within the last 12 months. Also updating rationale and references.
01/01/2024	New Policy