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.
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.
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:
Equivocal nuclear perfusion (MPI) stress test
Individual is obese (BMI >30 kg/m2)
Individual has large breasts or breast implants
Routine use in post cardiac transplant assessment
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, the express terms of the health plan will govern.
Cardiac sarcoidosis is a rare condition in which clusters of white blood cells, called granulomas, form in the tissue of the heart.
Blankenship, 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. (2018, May). Cardiac imaging policy. Retrieved August 1, 2018 from www.evicore.com. (6 articles and/or guidelines reviewed)
Okumura, W., Iwasaki, T., Toyama, T., Iso, T., Arai, M., et al. (2004). Usefulness of fasting F-FDG PET in identification of cardiac sarcoidosis. Journal of Nuclear Medicine, 45 (12), 1989-1998. (Level 3 evidence)
Yoshinaga, K., Chow, B., Williams, K., Chen, L., deKemp, R., Garrard, L., et. al. (2006) What is the Prognostic Value of Myocardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography? Journal of the American College of Cardiology. 48 (5), 1029-1039. (Level 4 evidence)
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 metaanalysis including the Ontario experience. Journal of Nuclear Medicine, 53, 241-248. (Level 1 evidence)
ORIGINAL EFFECTIVE DATE: 3/9/2017
MOST RECENT REVIEW DATE: 12/30/2018
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.
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