Medical Specialty Solutions Program Tip Sheet for Prior Authorization of Cardiac Services Form

Blue Cross Complete of Michigan LLC is an independent licensee of the Blue Cross and Blue Shield Association. Evolent (formally National Imaging Associates, Inc.) Medical Specialty Solutions
“Cardiac Solution” Program Tip Sheet for Prior-Authorization of Cardiac Services Provider requests for the following cardiac studies are reviewed by board-certified internists with specialized cardiac training and board-certified cardiologists:
• Myocardial perfusion imaging • Stress echocardiography, often preferred over MPI, due to lower cost and absence of radiation exposure (See separate Tip Sheet for choice of MPI vs. SE) • Coronary computed tomographic angiography • Cardiac PET, MRI, CT and EBCT may be considered part of a cardiac solution, or alternatively, included in a radiology benefits management program. • Echocardiography, either transthoracic (TTE) or transesophageal (TEE) • Prior authorization isn’t required for EKG treadmill stress testing without imaging, which may be more appropriate for certain member subgroups, as described in the guideline documents. Important data when medical records are required for prior authorization: • Symptoms and rationale for visit with cardiologist • Functional limitations and comorbidities (COPD, renal, stroke, chemotherapy, etc.) • Cardiac risk factors, lipid levels when available • Cardiac history and prior cardiac surgery or intervention • Relevant noncardiac history, especially respiratory history and smoking history • Medication, particularly antianginal medication, respiratory medication and anti GERD medication, with appropriate emphasis on adequate therapy for BP, angina, respiratory illness, congestive heart failure • Vital signs, including BMI, BP, HR, respiratory rate, and pulse oximetry and pertinent physical exam findings Radiation Exposure MPI: 7 - 24 mSv SE: 0 mSv Chest X-Ray: 0.06 mSv Annual Background: 3 mSv

 (For comparison)

Radiation exposure should be limited when possible.

Blue Cross Complete NIA Tip Sheet for Cardiac Solutions - Page 2 of 2

*Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference, Blue Cross Complete doesn’t control these sites and isn’t responsible for their content. • Any recent cardiac imaging tests (stress testing, echocardiogram, etc.). Actual EKG (rest and any exercise) and pertinent EKG rhythm tracing; troponin and BNP when relevant • Relevant non-cardiac evaluation results: for example, in dyspnea cases ― chest X- ray, d-dimer, CT scan of chest, pulmonary function tests.
• Provider’s diagnostic impressions, working diagnoses, clinical concerns

Examples of highly pertinent data from the medical record:

• Stress testing: age, description of symptoms, functional limitations, cardiac history, risk factors, comorbidities (COPD, renal, stroke, chemotherapy, etc.), antianginal medication, VS and exam, EKG tracing, troponin.
• Echocardiography: symptoms or history suggestive of structural heart disease, particularly shortness of breath, chest pain, syncope/presyncope, thromboembolic events, prior myocardial infarction, cardiac surgery, or coronary revascularization without known left ventricular ejection fraction, prominent/loud systolic or any diastolic heart murmurs, rales, lower extremity edema, unexplained hypoxia, EKG changes, arrhythmias, radiographic evidence of congestive heart failure.

Pediatric echocardiography guidelines focus on a different spectrum of cardiac pathology:

• Congenital: cyanosis, failure to thrive, syncope, chest pain, abnormal murmurs, prior surgery, arrhythmogenic cardiomyopathy, pulmonary hypertension.
• Acquired: Kawasaki disease, infective endocarditis and sepsis, pericarditis, HIV myocarditis, toxic cardiomyopathy, thromboembolism, rheumatic heart disease.