Cardiovascular Nuclear Medicine

LCD Information Document Information Source LCD ID N/A LCD ID L33960 Original ICD-9 LCD ID Not Applicable LCD Title Cardiovascular Nuclear Medicine Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/29/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-04, Medicare Claims Processing, Chapter 12: 70: Payment conditions for radiology services CMS Publication 100-04, Medicare Claims Processing, Chapter 13: 20: Payment conditions for radiology services 50: Payment for the supply of a radiopharmaceutical diagnostic imaging agent and/or pharmacologic stressing agent with diagnostic nuclear medicine procedures. 90: Services of portable X-Ray suppliers Coverage Indications, Limitations, and/or Medical Necessity Abstract:Cardiovascular nuclear imaging employs non-invasive techniques to assess alterations in coronary artery flow, and ventricular function. The specific imaging technique (perfusion versus ventricular function) and the reason for the imaging determine which radionuclide agent is employed. A myocardial perfusion study utilizes an imaging isotope agent that reflects segmental and global myocardial blood flow and uptake, the interpretation of which is used to make inference about the presence of scar and ischemia. Ventricular function studies utilize specific imaging isotopes to outline the borders of the ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle, synchronized with the electrocardiogram, is used to generate wall motion and ejection fraction information. These tests may be performed at rest and during exercise, or with pharmacologic intervention when exercise cannot be performed. The acquisition of the images may be planar (single plane) or by multiple planes with computer integration, SPECT (single-photon emission computer tomography). Indications: Cardiovascular nuclear imaging is indicated for the following:Assessment of the functional and prognostic importance of angina;Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy;Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years; Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction;Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned;Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures;Quantification and surveillance of myocardial infarction and prognostication in patients with infarction;Assessment of congenital anomalies of coronary arteries;Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in: patients with minor or intermediate clinical risk predictors and poor functional capacity; patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity undergoing high risk non-cardiac surgery; The "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery" (JACC 2007; 50:e159-e242) provides this information: High risk surgery: aortic and peripheral vascular surgery Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery. Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery Poor functional capacity = less than 4 METS Clinical risk factors: 1) history of ischemic heart disease 2) history of compensated or prior heart failure 3) history of cerebrovascular disease 4) diabetes mellitus 5) renal insufficiency Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management.Evaluation of ventricular function in patients with non-ischemic myocardial disease;Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker;Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin).First pass studies will be considered medically necessary only when information sought is immediately relevant to the management of the patient’s clinical condition, and has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts.Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by EKG or enzyme testing. Patient selection should be based on clinical grounds:Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making. Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant. Limitations:Special Equipment Requirements:Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies.The rapid uptake, relatively low photon energy and redistribution of thallium 201 preclude its application to studies for gated images in most laboratories. However, an exception will be made to allow this combination for laboratories that have at least double-headed cameras and the appropriate software to facilitate the count. Such providers must certify that their laboratories are specially equipped to process such studies. Cardiac blood pool imaging studies with appropriate add-on may be reported on a single date of service.All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-physician provider. All stress tests must be performed under the direct supervision of a physician. The nuclear test components must be performed under the general supervision of a physician. Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare.Tests that are anticipated to provide information duplicative of another test already performed will be denied as not medically necessary.Tests performed when the results would not be anticipated to influence medical management decisions will be denied as not medically necessary. Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan will denied as not medically necessary.Infarct avid scintigraphy will be denied if the diagnosis of myocardial infarction has already been confirmed by enzymes and/or EKG.Tests performed unrelated to changes in a patient's signs or symptoms, or for immediate pre-operative evaluation will be denied as medically unnecessary.Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test will be considered medically unnecessary and denied.Tests performed for preoperative evaluation in patients undergoing low-risk surgery will be denied. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: Cardiovascular nuclear imaging employs non-invasive techniques to assess alterations in coronary artery flow, and ventricular function. The specific imaging technique (perfusion versus ventricular function) and the reason for the imaging determine which radionuclide agent is employed. A myocardial perfusion study utilizes an imaging isotope agent that reflects segmental and global myocardial blood flow and uptake, the interpretation of which is used to make inference about the presence of scar and ischemia. Ventricular function studies utilize specific imaging isotopes to outline the borders of the ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle, synchronized with the electrocardiogram, is used to generate wall motion and ejection fraction information. These tests may be performed at rest and during exercise, or with pharmacologic intervention when exercise cannot be performed. The acquisition of the images may be planar (single plane) or by multiple planes with computer integration, SPECT (single-photon emission computer tomography). Indications: Cardiovascular nuclear imaging is indicated for the following: Assessment of the functional and prognostic importance of angina; Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy; Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years; Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction; Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned; Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures; Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; Assessment of congenital anomalies of coronary arteries; Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in: patients with minor or intermediate clinical risk predictors and poor functional capacity; patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity undergoing high risk non-cardiac surgery; The "ACA/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery" (JACC 2007; 50:e159-e242) provides this information: High risk surgery: aortic and peripheral vascular surgery Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery. Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery Poor functional capacity = less than 4 METS Clinical risk factors: 1) history of ischemic heart disease 2) history of compensated or prior heart failure 3) history of cerebrovascular disease 4) diabetes mellitus 5) renal insufficiency Decision-making for testing is based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery and the likelihood that the results of the cardiac testing would change the management. Evaluation of ventricular function in patients with non-ischemic myocardial disease; Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker; Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin). First pass studies will be considered medically necessary only when information sought is immediately relevant to the management of the patient’s clinical condition, and has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts. Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by EKG or enzyme testing. Patient selection should be based on clinical grounds: Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making. Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant. Limitations: Special Equipment Requirements: Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies. The rapid uptake, relatively low photon energy and redistribution of thallium 201 preclude its application to studies for gated images in most laboratories. However, an exception will be made to allow this combination for laboratories that have at least double-headed cameras and the appropriate software to facilitate the count. Such providers must certify that their laboratories are specially equipped to process such studies. Cardiac blood pool imaging studies with appropriate add-on may be reported on a single date of service. All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-physician provider. All stress tests must be performed under the direct supervision of a physician. The nuclear test components must be performed under the general supervision of a physician. Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare. Tests that are anticipated to provide information duplicative of another test already performed will be denied as not medically necessary. Tests performed when the results would not be anticipated to influence medical management decisions will be denied as not medically necessary. Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan will denied as not medically necessary. Infarct avid scintigraphy will be denied if the diagnosis of myocardial infarction has already been confirmed by enzymes and/or EKG. Tests performed unrelated to changes in a patient's signs or symptoms, or for immediate pre-operative evaluation will be denied as medically unnecessary. Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test will be considered medically unnecessary and denied. Tests performed for preoperative evaluation in patients undergoing low-risk surgery will be denied.