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 Foundation/American Heart Association. (2013). Guideline for the Management of Heart Failure. Retrieved May 12, 2016 from http://my.americanheart.org/statements.

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2017). Myocardial sympathetic innervation imaging in patients with heart failure (6.01.56). Retrieved February 19, 2018 from BlueWeb. (24 articles and/or guidelines reviewed)

Doi, T., Nakata, T., Hashimoto, A., Yuda, S., Wakabayashi, T., Kouza, H., et al. (2012). Synergistic prognostic values of cardiac sympathetic innervation with left ventricular hypertrophy and left atrial size in heart failure patients without reduced left ventricular ejection fraction: A cohort study. BMJ Open, 2 (6), 1-11. (Level 3 evidence)

Nakata, T., Kakajima, K., Yamashina, S., Yamada, T., Momose, M., Kasama, S., et al. (2013). A pooled analysis of multicenter cohort studies of 123 I-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.

Palmetto GBA. (2018). LCD for non-covered category III CPT codes (L34555). Retrieved February 20, 2018 from www.cms.gov.

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)

U. S. Food and Drug Administration. (2013, March). Center for Drug Evaluation and Research. AdreView. Retrieved July 25, 2013 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022290s001lbl.pdf.

Verschure, D., Veltman, C., Manrique, A., Somsen, A., Koutelou, M., Katsikis, A., et al. (2014). For what endpoint does myocardial 123 I-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:  3/8/2018

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