BlueCross BlueShield of Tennessee Medical Policy Manual

Positron Emission Tomography (PET) for Cardiac Applications

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

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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

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  

ID_EC

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