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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. Harvard Pilgrim Health Care—Provider Manual H.194 (continued) December 2016 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 Harvard Pilgrim Health Care—Provider Manual (continued) H.195 December 2016 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) H.196 December 2016 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. Harvard Pilgrim Health Care—Provider Manual H.197 December 2016