Download Nuclear Cardiac Imaging and Myocardial Perfusion Study

Payment Policies
Nuclear Cardiac Imaging
and Myocardial Perfusion Study
Policy
Harvard Pilgrim reimburses contracted providers for nuclear cardiac imaging and myocardial perfusion studies for assessing heart disease.
Harvard Pilgrim’s nuclear cardiac imaging and myocardial perfusion studies is managed through an arrangement with
National Imaging Associated (NIA). For additional information, see Harvard Pilgrim’s Outpatient Advanced Imaging
Authorization policy.
Policy Definition
Single Photon Emission Computed Tomography is a nuclear medicine tomographic imaging technique using gamma
rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to
provide true 3D information. This information is typically presented as cross-sectional slices through the patient, but can
be freely reformatted or manipulated, as required.
The Myocardial Perfusion Scan is a nuclear medicine procedure that illustrates the function of the heart muscle myocardium. This scan evaluates many heart conditions from coronary artery disease (CAD) to hypertropic cardiomyopathy and
myocardial wall motion abnormalities. The function of the myocardium is also evaluated by calculating the left ventricular ejection fraction (LVEF) of the heart.
Prerequisite(s)
HMO/POS/PPO
Authorization is required for non-emergency, outpatient advanced imaging services. Ordering physicians are required to
contact NIA to initiate the request. (Refer to Outpatient Advanced Imaging Authorization for specific requirements.)
Connecticut Open Access HMO
Note: For the Connecticut Open Access HMO product, no referral is required to see a contracted specialist.
Harvard Pilgrim Reimburses
1
HMO/POS/PPO
Harvard Pilgrim reimburses nuclear cardiac imaging and myocardial perfusion studies for covered indications. See
“Provider Billing Guidelines and Documentation” section of this policy for a complete list of covered CPT, HCPCS and
diagnosis codes.
Cardiac Evaluation for Patient with Suspected CAD
• Detection of CAD Asymptomatic (without ischemic equivalent):
- High CHD risk (ATP III Risk criteria).
- Intermediate CHD risk (ATP III risk criteria), ECG uninterpretable.
Detection Of CAD/Risk Assessment Symptomatic: Evaluation of Ischemic Equivalent (Non-Acute)
• Low pretest probability or CAD, ECG uninterpretable or unable to exercise.
• Intermediate pretest probability of CAD, ECG interpretable and able to exercise, or unable to exercise.
• High pretest probability of CAD, regardless of ECG interpretability and ability to exercise.
• Detection of CAD Asymptomatic (without ischemic equivalent):
- New onset or newly diagnosed heart failure with LV systolic dysfunction without ischemic equivalent: No prior CAD
evaluation and no planned coronary angiography.
- New onset atrial fibrillation: Part of evaluation when etiology unclear.
- Ventricular Tachycardia: Low CHD risk (ATP III risk criteria) or Intermediate or high CHD risk (ATP III risk criteria).
- Syncope: Intermediate or high CHD risk (ATP III risk criteria).
- Elevated Troponin: Troponin elevation without additional evidence of acute coronary syndrome (when ischemia present patient is not subject to Stress Echo contraindications).
Cardiac Evaluation for Patient with Known CAD with New or Changing Symptoms
• New or worsening symptoms with abnormal coronary angiography or abnormal prior stress imaging study.
• New or worsening symptoms with normal coronary angiography or normal prior stress imaging study.
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Payment Policies
Nuclear Cardiac Imaging and Myocardial Perfusion Study (cont.)
Cardiac Evaluation for Patient with Known CAD and No New or Changing Symptoms
• Equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern.
• Intermediate to high CHD risk (ATP III risk criteria), last stress imaging study done more than or equal to 2 years ago. If
known CAD, not subject to Stress Echo contraindications.
• Known CAD on coronary angiography OR prior abnormal stress imaging study; last stress imaging study done more
than or equal to 2 years ago.
• Equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern.
• Asymptomatic prior coronary calcium Agatston score:
- Low to intermediate CHD risk, Agatston score between 100 and 400.
- High CHD risk, Agatston score between 100 and 400.
- Agatston score greater than 400.
• Intermediate or high risk Duke treadmill score.
Other Indications
• Intermediate risk surgery: greater than or equal to 1 clinical risk factor. Poor or unknown functional capacity (less than
4 METS).
• Vascular Surgery: Greater than or equal to 1 clinical risk factor. Poor or unknown functional capacity (less than 4
METS).
• Coronary angiography (invasive or noninvasive): Coronary stenosis or anatomic abnormality of uncertain significance
• STEMI: Hemodynamically stable, no recurrent chest pain symptoms or no signs of HF. To evaluate for inducible ischemia. No prior coronary angiography.
• UA/NSTEMI: Minor perioperative risk predictor. Normal exercise to tolerance (greater than or equal to 4 METS) Hemodynamically stable, no recurrent chest pain symptoms or no signs or HF. To evaluate for inducible ischemia. No prior
coronary angiography.
Risk Assessment: Post Revascularization (PTCA or CABG)
• Symptomatic
- Evaluation of ischemic equivalent
• Asymptomatic
- Incomplete revascularization. Additional revascularization feasible.
- Less than 5 years after CABG AND no MPI for 2 years or more unless most recent MPI showed reversible ischemia.
- Greater than or equal to 5 years after CABG AND no MPI for 2 years or more unless most recent MPI showed revers
ible ischemia.
- Greater than or equal to 2 years after PCI.
Assessment of Viability/Ischemia)
Ischemic Cardiomyopathy/Assessment of viability for known severe LV dysfunction. Patient eligible for revascularization.
MPI Qualification
To qualify for MPI, patient must meet ACCF/ASNC appropriateness criteria for appropriate indications above and meets
any one of the following conditions:
• Stress echo is not indicated, or
• Stress echo has been performed however findings were inadequate, there were technical difficulties with interpretation, or results were discordant with previous clinical data, or
• MPI is preferential to stress echo for specified conditions
Harvard Pilgrim Does Not Reimburse
HMO/POS/PPO
Nuclear Cardiac Imaging and Myocardial Perfusion Studies for non-covered indications. Claims submitted with noncovered indications will be denied as provider liable. This applies to professional component only (modifier 26), technical
component only (TC), or global services.
• Asymptomatic patient with risk factors
• Chest pain with normal EKG and ability to exercise despite risk factors
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Payment Policies
Nuclear Cardiac Imaging and Myocardial Perfusion Study (cont.)
• Prescreen for Viagra without symptoms and/or risk factors
• Employment related requirements
• Heart transplant — refer for MD review
• Same test being performed < 6 weeks apart unless specific guideline criteria states otherwise
• Additional images for same or poor, or contrast enhanced study
Member Cost-Sharing
Services subject to applicable member out-of-pocket cost (e.g., copayment, coinsurance, deductible).
Provider Billing Guidelines and Documentation
Coding2
Nuclear Cardiac Imaging and Myocardial Perfusion Study — CPT/HCPCS and ICD-9/ICD-10 Covered Indications
CPT/HCPCS
Description
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)
Comments
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
ICD-9 Covered Indications
ICD-10 Covered Indications
Related Policies
• Outpatient Advanced Imaging Authorization Policy
PUBLICATION HISTORY
01/15/10 05/15/10
01/15/11
new policy effective 04/01/10
update to covered and non-covered indications; removed combo studies from “Harvard Pilgrim Does Not Reimburse” section
coding update; update to covered indications effective 01/15/11 for guideline
Harvard Pilgrim Health Care—Provider Manual
(continued)
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Payment Policies
Nuclear Cardiac Imaging and Myocardial Perfusion Study (cont.)
02/15/11
10/15/11
01/01/12
01/15/12
01/15/13
12/15/13
06/15/14
12/15/14
06/15/15
12/15/15
12/15/16
minor edits for clarity
update to covered indications effective 01/01/12 for guideline
removed First Seniority Freedom information from header
added covered diags 10/01/11 ICD-9 release update; update to covered indication effective 04/01/12 for guideline
minor updates for clarification; end dated 78494–no longer included in this policy
annual review; no changes
added Connecticut Open Access HMO referral information to prerequisites
annual review; removed CPT 78494 from coding grid — effective 04/01/13, no longer included in this policy
ICD-10 coding update
annual review; no changes
annual review; no changes
1This policy applies to the products of Harvard Pilgrim Health Care and its affiliates—Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health
Care of New England, and HPHC Insurance Company—for services performed by contracted providers. Payment is based on member benefits and eligibility, medical necessity review, where applicable, and provider contractual agreement. Payment for covered services rendered by contracted providers
will be reimbursed at the lesser of charges or the contracted rate. (Does not apply to inpatient per diem, DRG, or case rates.) HPHC reserves the right to
amend a payment policy at its discretion. CPT and HCPCS codes are updated annually. Always use the most recent CPT and HCPCS coding guidelines.
2The table may not include all provider claim codes related to PET imaging.
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