DESCRIPTION
Positron emission tomography (PET) images biochemical reactions and physiological functions by measuring concentrations of radioactive chemicals that are partially metabolized in the body region of interest. Radiopharmaceuticals or tracers used for PET are introduced into the body by intravenous injection or by respiration.
POLICY
Positron emission tomography (PET) for cardiac applications is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Positron emission tomography (PET) to determine absolute quantitation of myocardial blood flow is considered investigational.
Any positron emission tomography (PET) device utilized for this procedure must have FDA approval specific to the indication; otherwise, its use will be considered investigational.
MEDICAL APPROPRIATENESS
Positron emission tomography (PET) for cardiac applications is considered medically appropriate for ANY ONE of the following indications:
Assess myocardial viability when ANY ONE of the following are met:
Individual with significant left ventricular dysfunction under consideration for revascularization (i.e., coronary artery bypass graft or percutaneous coronary intervention)
Individual with known or suspected cardiac sarcoid for ANY ONE of the following:
To confirm diagnosis
To monitor response to therapy
Assess cardiac perfusion when ANY ONE of the following are met:
Meets medical necessity criteria for an imaging stress test and ANY ONE of the following:
Individual is severely obese (for example BMI >30 kg/m2)
Individual has large breasts or breast implants
Individual is incapable of exercise due to physical (musculoskeletal or neurological) inability to achieve target heart rate. Target heart rate is calculated as 85 percent of the maximum age predicted heart rate (MPHR). MPHR is estimated as 220 minus the individual’s age.
Equivocal nuclear perfusion (single-photon emission computed tomography [SPECT] myocardial perfusion imaging [MPI]) stress test
Routine use in post heart transplant assessment of transplant coronary artery disease
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Cardiac sarcoidosis is a rare condition in which clusters of white blood cells, called granulomas, form in the tissue of the heart.
SOURCES
American Society of Nuclear Cardiology, Society of Nuclear Medicine & Molecular Imaging. (2016). ASNC & SNMMI joint position statement on the clinical indications for myocardial perfusion PET. Retrieved Afugust 24, 2021 from www.asnc.org/.
Blankstein, R., Osborne, M., Naya, M., Waller, A., Kim, C.K., Murthy, V.L., et al. (2014). Cardiac positron emission tomography enhances prognostic assessments of patients with suspected cardiac sarcoidosis. Journal of American College of Cardiology, 63 (4), 329-336. (Level 4 evidence)
Einstein, A., Moser, K., Thompson, R., Cerqueira, M. D., & Henzlova, M.J. (2007). Radiation dose to patients from cardiac diagnostic imaging. Circulation, 116, 1290-1305. (Level 5 evidence)
eviCore healthcare. (2023, July). Cardiac imaging policy. Retrieved September 20, 2023 from www.evicore.com. (10 articles and/or guidelines reviewed)
Youssef, G., Leung, E., Mylonas, I., Nery, P., Williams, K., Wisenberg, G., et al. (2012). The use of F-FDG PET in the diagnosis of cardiac sarcoidosis: a systematic review and meta-analysis including the Ontario experience. Journal of Nuclear Medicine, 53, 241-248. (Level 1 evidence)
ORIGINAL EFFECTIVE DATE: 3/9/2017
MOST RECENT REVIEW DATE: 1/30/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.