BlueCross BlueShield of Tennessee Medical Policy Manual

Myocardial Sympathetic Innervation Imaging for Individuals with Heart Failure

DESCRIPTION

In individuals with heart failure, activation of the sympathetic nervous system is an early mechanism to compensate for decreased myocardial function. Overactive sympathetic innervation associated with heart failure involves increased neuronal release of norepinephrine, the main neurotransmitter of the cardiac sympathetic nervous system. The scintigraphic imaging agent iodine 123 meta-iodobenzylguanidine (MIBG) is proposed as a prognostic marker in individuals with heart failure to aid in the identification of individuals at risk of one- and two-year mortality. Once the agent is administered, planar images of the thorax are acquired at fifteen minutes and then at four hours, measuring the heart to mediastinum (H/M) ratio.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

There is a lack of evidence to support the finding that MIBG imaging can be used to direct management in individuals with heart failure.

SOURCES 

ACCF/ACR/ASE/ASNC/SCCT/SCMR. (2013). Appropriate Utilization of Cardiovascular Imaging in Heart Failure. Retrieved May 12, 2016 from www.acr.org.

American College of Cardiology. American Heart Association. Heart Failure Society of America. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure.  Retrieved December 11, 2018 from ECRI Guidelines Trustâ„¢. (Guideline ID: 485)

BlueCross BlueShield Association. Evidence Positioning System. (9:2018). Myocardial sympathetic innervation imaging in patients with heart failure (6.01.56). Retrieved December 11, 2018 from https://www.evidencepositioningsystem.com/.  (24 articles and/or guidelines reviewed)

CMS.gov. Centers for Medicare & Medicaid Services. Palmetto GBA. (2018, September). LCD for non-covered category III CPT codes (L34555). Retrieved December 11, 2018 from www.cms.gov.

Nakata, T., Kakajima, K., Yamashina, S., Yamada, T., Momose, M., Kasama, S., et al. (2013). A pooled analysis of multicenter cohort studies of 123I-mIBG imaging of sympathetic innervation of assessment of long-term prognosis in heart failure. Journal of the American College of Cardiology: Cardiovascular Imaging, 6 (7), 772-784. (Level 2 evidence)

National Heart, Lung, and Blood Institute. (2011). Report of the National Heart, Lung, and Blood Institute working group on the translation of cardiovascular molecular imaging. Circulation, 123 (19), 2157-2163.

Shah, A. M., Bourgoun, M., Narula, J., Jacobson, A. F., & Solomon, S. D. (2012). Influence of ejection fraction on the prognostic value of sympathetic innervation imaging with iodine-123 MIBG in heart failure. JACC: Cardiovascular Imaging, 5 (11), 1139-1146. (Level 2 evidence)

Technology Evaluation Center. (2013). Myocardial sympathetic innervation imaging in heart failure. (Vol. 28, No. 12) Retrieved May 18, 2015 from http://www.bcbs.com/blueresources/tec/tec-assessments.html#topics.

Treglia, G., Stefanelli, A., Bruno, I., & Giordano, A. (2013). Clinical usefulness of myocardial innervations imaging using iodine-123-meta-iodobenzylguanidine scintigraphy in evaluating the effectiveness of pharmacological treatments in patients with heart failure: An overview. European Review for Medical and Pharmacological Sciences, 17 (1), 56-68. (Level 2 evidence)

Verschure, D., Veltman, C., Manrique, A., Somsen, A., Koutelou, M., Katsikis, A., et al. (2014). For what endpoint does myocardial 123I-MIBG scintigraphy have the greatest prognostic value in patients with chronic heart failure? Results of a pooled individual patient data meta-analysis. European Heart Journal - Cardiovascular Imaging, 15, 996-1003. (Level 2 evidence)

ORIGINAL EFFECTIVE DATE:  12/14/2013

MOST RECENT REVIEW DATE:  1/10/2019  

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