RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT) Form

This document addresses use of the radiopharmaceutical tracer ¹²³iodine meta-iodobenzylguanidine (also known as ¹²³I-MIBG or MIBG, or AdreView^™) for cardiac imaging to assist with identification of individuals at increased risk of short-term mortality associated with heart failure (HF). MIBG has been proposed as a prognostic marker in individuals with HF. The tracer agent can be used with or without single-photon emission computed tomography (SPECT) imaging.

Note: This document addresses cardiac imaging with ¹²³iodine meta-iodobenzylguanidine, (also known as ¹²³I-MIBG or MIBG), and does not address oncologic indications for use of this radiotracer.

Position Statement

Investigational and Not Medically Necessary:

Myocardial sympathetic innervation imaging with ¹²³iodine meta-iodobenzylguanidine (MIBG) is considered investigational and not medically necessary for all indications, including the evaluation of heart failure.