HumanaCommercial Clinical Policy

Humana Cardiac Single Photon Emission Computed Tomography Form


Cardiac Single Photon Emission Computed Tomography (SPECT)

Notes: Cardiac SPECT deemed urgent/emergent is not subject to the criteria within this medical coverage policy.

Indications

(503373) Is the patient able to exercise? 
(503374) Is the patient asymptomatic? 
(503375) Does the patient have coronary heart disease, high risk, as indicated by a calculated 10-year absolute coronary heart disease risk greater than or equal to 20% by a global risk calculator? 
(503376) Does the patient have a coronary heart disease risk equivalent condition (e.g., abdominal aortic aneurysm, carotid artery disease, peripheral arterial disease)? 
(503377) Does the patient have diabetes mellitus? 

YesNoN/A
YesNoN/A
YesNoN/A

Sign up to see the rest of the questions

Unlock the remaining questions and the full coverage workflow.

Sign up for free
Effective Date

10/03/2023

Last Reviewed

NA

Original Document

  Reference



Description

Cardiac single-photon emission computed tomography (SPECT) is a noninvasive nuclear imaging test used to evaluate myocardial perfusion (blood flow) and viability (cellular, metabolic and contractile function of the cells). Decreased cardiac blood flow or function may indicate conditions such as coronary artery disease or myocardial infarction (MI). This procedure is also known as myocardial perfusion imaging (MPI) or nuclear stress testing, and may be completed while the individual is resting, physically exercising or given a medication to simulate exercise.

SPECT scans use gamma ray-producing radioactive tracers which are injected into the blood. The tracer signals are then captured by a gamma camera and converted into images of the heart.

Effective Date: 10/03/2023

Revision Date: 10/03/2023

Review Date: 08/24/2023

Policy Number: HUM-0600-003

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Cardiac single-photon emission computed tomography (SPECT) deemed urgent/emergent (eg, acute chest pain, acute coronary syndrome) is not subject to the criteria within this medical coverage policy.

Exercise Stress/Rest Cardiac SPECT MPI

Humana members may be eligible under the Plan for exercise stress/rest cardiac SPECT MPI when the following criteria are met:

  • Individual is able to exercise;
  • AND ANY of the following:
    • Asymptomatic individual;
    • AND BOTH of the following:
      • Coronary heart disease, high risk, as indicated by one or more of the following:
        • Calculated 10-year absolute coronary heart disease risk greater than or equal to 20% by global risk calculator; OR
        • Coronary heart disease risk equivalent (eg, abdominal aortic aneurysm, carotid artery disease, peripheral arterial disease); OR
        • Diabetes mellitus; OR
        • Prior stroke or transient ischemic attack; AND
      • Exercise treadmill testing alone is or would be unreliable or inconclusive due to one or more of the following:

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Anginal symptoms induced by exercise in high risk individual with no diagnostic ECG changes on previous exercise treadmill test; OR
  • Atrial fibrillation or flutter; OR
  • Electronically paced ventricular rhythm; OR
  • Individual taking digoxin; OR
  • Insufficient workload (inability to achieve at least 85% of maximum predicted heart rate [MPHR] on Bruce protocol exercise treadmill testing); OR
  • Left bundle branch block; OR
  • Left ventricular hypertrophy with repolarization abnormalities on baseline ECG; OR
  • Pre-excitation syndrome (eg, Wolff-Parkinson-White syndrome); OR
  • ST-segment on baseline ECG with 1 mm depression or greater; OR

CAD

Coronary artery disease (CAD); AND EITHER of the following:

  • Known CAD and need for further evaluation, as indicated by BOTH of the following:
    • Exercise treadmill testing alone is or would be unreliable or inconclusive; AND
    • Clinically significant coronary artery disease, as indicated by one or more of the following:
      • Anomalous coronary artery and need for functional assessment; OR
      • Following ST-segment elevation myocardial infarction; OR
      • History of Kawasaki disease with known coronary artery aneurysm and need to demonstrate inducible ischemia; OR
  • Change in clinical condition, as indicated by one or more of the following:
    • Increased ischemic symptom frequency or severity; OR
    • Increased heart failure symptoms (eg, dyspnea, edema, fatigue); OR
    • New onset cardiac or noncardiac chest pain without ECG changes; OR
    • New ST-segment changes on ECG at rest; OR

Detection of recurrent stenosis or progression of disease in asymptomatic individual with silent ischemia prior to revascularization and one or more of the following:

  • Diabetes mellitus; OR
  • History of prior cardiac arrest; OR
  • Incomplete prior revascularization procedure (eg, persistent stenosis after percutaneous coronary intervention or coronary artery bypass grafting); OR
  • Involvement of proximal left anterior descending artery; OR
  • Left ventricular ejection fraction of 35% or less; OR
  • Greater than 5 years after coronary artery bypass grafting; OR
  • Greater than 2 years after percutaneous coronary intervention (eg, angioplasty or stent); OR

Following acute coronary syndrome and ALL of the following:

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Absence of ischemic symptoms (eg, chest pain, dyspnea, rapid heart rate); AND
  • Early revascularization not planned; AND
  • No signs of heart failure (eg, dyspnea, edema, and/or fatigue) or hemodynamic instability (eg, unstable heart rate and/or blood pressure); OR

Stable ischemic heart disease and BOTH of the following:

  • New, recurrent or worsening symptoms (eg, exertional dyspnea and/or fatigue); AND
  • Symptoms not consistent with unstable angina (unexpected chest pain at rest); OR

Suspected CAD, as indicated by one or more of the following:

  • Asymptomatic individual with elevated troponin level; OR
  • Asymptomatic individual with ischemic changes present on resting ECG; OR
  • Chronic secondary mitral regurgitation and need to establish possible ischemic etiology; OR
  • Equivocal results on exercise treadmill test requiring further evaluation; OR
  • Known congenital heart disease (eg, coronary artery compression, previous coronary reimplantation, repaired aortic coarctation); OR
  • New onset arrhythmia, as indicated by one or more of the following:
    • Frequent premature ventricular contractions (one or more on 12-lead ECG or more than 30 per hour on ambulatory Holter monitoring); OR
    • Supraventricular tachycardia in individual with one or more cardiac risk factors ; OR
    • Ventricular tachycardia; OR
  • Diabetes mellitus with high clinical suspicion of coronary artery disease; AND one or more of the following:
    • Abnormal resting ECG; OR
    • Cardiac or noncardiac chest pain or angina equivalent (eg, exertional dyspnea); OR
    • Diabetic complications (eg, autonomic neuropathy); OR
    • Peripheral arterial disease; OR

Heart failure, cardiomyopathy or ventricular dysfunction, known or suspected, with the need for additional evaluation; AND one or more of the following:

  • Assessment for myocardial viability to determine need for revascularization; OR
  • Diagnosis of cardiomyopathy in individual with systemic disease (eg, amyloidosis, sarcoidosis); OR
  • Evaluation of left ventricular function and ejection fraction prior to receiving doxorubicin or other cardiotoxic drug for cancer chemotherapy; OR
  • Need to differentiate ischemic from nonischemic etiology in unexplained dilated cardiomyopathy; OR
Nonacute chest pain or ischemic equivalent;

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • AND ALL of the following:
    • Cardiac risk factors, one or more present; AND
    • Exercise treadmill testing alone is or would be unreliable or inconclusive; AND
    • Evaluation of chest pain needed, as indicated by one or more of the following:
      • Cardiac chest pain, as indicated by ALL of the following:
        • Deep, poorly localized chest or arm pain or discomfort; AND
        • Relieved within 5 to 15 minutes by rest or sublingual nitroglycerin; AND
        • Reproducible with physical exertion or emotional stress; OR
      • Possible cardiac chest pain, as indicated by BOTH of the following:
        • At-risk age group, as indicated by EITHER of the following:
          • Male 30 years of age or older; OR
          • Female 40 years of age or older; AND
        • Cardiac chest pain symptoms, as indicated by two or more of the following:
          • Deep, poorly localized chest or arm pain or discomfort; OR
          • Relieved in 5 to 15 minutes by rest or sublingual nitroglycerin; OR
          • Reproducible with physical exertion or emotional stress; OR
        • Noncardiac chest pain, as indicated by nonspecific chest pain, and EITHER of the following:
          • Male 40 years of age or older; OR
          • Female 50 years of age or older or menopausal; OR
      • Preoperative or preprocedural cardiovascular evaluation needed; AND EITHER of the following:
        • Prior to arterial vascular surgery (eg, aortic aneurysm, aortofemoral or aortoiliac bypass) in individual with good functional capacity (eg, able to climb a flight of stairs or walk up a hill); AND BOTH of the following:
          • Clinical risk factors, as indicated by one or more of the following:
            • Chronic kidney disease; OR
            • Diabetes mellitus; OR
            • History of one or more of the following:
              • Arrhythmia; OR
              • Cerebrovascular disease; OR
              • Heart disease (eg, ischemic, valvular); OR
              • Heart failure; AND
            • Exercise treadmill testing alone is or would be unreliable or inconclusive; OR
          • Prior to intermediate-risk noncardiac surgery (eg, abdominal or thoracic surgery, hip replacement) in individual with good functional capacity (eg, able to climb flight of stairs or walk up a hill); AND BOTH of the following:
            • Clinical risk factors, as indicated by one or more of the following:
              • Chronic kidney disease; OR
              • Diabetes mellitus; OR
              • History of one or more of the following:
                • Arrhythmia; OR
                • Cerebrovascular disease; OR

        Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        • Heart disease (eg, ischemic, vascular); OR
        • Heart failure; OR
        • Peripheral arterial disease (eg, abdominal aortic aneurysm, carotid artery disease, lower extremity arterial disease); AND

        Result of testing will affect management of individual, as indicated by one or more of the following:

        • Change in anesthesia management; OR
        • Initiation of treatment (eg, use of pre-or perioperative beta-blocker); OR
        • Postponement or cancellation of surgery; OR
        • Repeat evaluation of specific area or structure with same imaging modality; AND
        • one or more of the following:
          • Change in clinical status (eg, new or worsening associated symptoms); OR
          • Need for interval reassessment that may impact treatment plan; OR
          • Repeat imaging required either prior to or after performance of invasive procedure38; OR
        • Syncope; AND BOTH of the following:
          • Cardiac risk factors, one or more present; AND
          • Exercise treadmill testing alone is or would be unreliable or inconclusive; AND

        Pharmacological Stress/Rest Cardiac SPECT MPI

        Humana members may be eligible under the Plan for pharmacologic stress/rest cardiac SPECT MPI when the following criteria are met:

        • Criteria listed above for exercise stress cardiac SPECT MPI are met;
        • AND EITHER of the following:
          • Pharmacological testing is indicated; AND one or more of the following:
            • Electronically paced rhythm or left bundle branch block; OR
            • Exercise contraindicated (eg, severe aortic disease such as aortic coarctation or thoracic aortic aneurysm or dissection, uncontrolled hypertension, uncontrolled ventricular arrhythmia); OR
            • Individual unable to exercise or achieve sufficient workload (eg, unable to achieve at least 85% of MPHR on Bruce protocol exercise treadmill testing); OR
            • Left bundle branch block on ECG; OR
          • Prior to arterial vascular surgery (eg, aortic aneurysm, aortofemoral or aortoiliac bypass) in individual with poor functional capacity (eg, unable to climb flight of stairs or walk up a hill) and the result of testing will affect management of the individual; AND one or more of the following indications:
            • Change in anesthesia management; OR
            • Initiation of treatment (eg, use of pre- or perioperative beta-blocker); OR
            • Postponement or cancellation of surgery39
        Coverage Limitations

        Humana members may NOT be eligible under the Plan for exercise stress/rest cardiac SPECT MPI for any indications other than those listed above including, but may not be limited to:

        • Cardiac risk assessment in an individual with end-stage renal disease; OR

        Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        • Post-revascularization in an asymptomatic individual; OR
        • Routine screening for coronary artery disease in an asymptomatic individual at low risk by global risk calculator38

        These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

        Humana members may NOT be eligible under the Plan for pharmacologic stress/rest cardiac SPECT MPI for any indications other than those listed above including, but may not be limited to:

        • Follow-up of normal stress SPECT imaging; OR
        • Routine screening for coronary artery disease in an asymptomatic individual at low risk by global risk calculator39

        These are considered experimental/investigational as they are identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

        Humana members may NOT be eligible under the Plan for absolute quantitation of myocardial blood flow with cardiac SPECT for any indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

        Additional information about cardiac SPECT may be found from the following websites:

        Background
        • American College of Cardiology
        • American Heart Association
        • National Heart, Lung and Blood Institute
        • National Library of Medicine

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023
        Revision Date: 10/03/2023
        Review Date: 08/24/2023
        Policy Number: HUM-0600-003
        Page: 12 of 21

        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        Medical Alternatives

        Alternatives to cardiac SPECT include, but may not be limited to, the following:

        • Stress ECG
        • Stress echocardiography

        Physician consultation is advised to make an informed decision based on an individual’s health needs.

        Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

        Provider Claims Codes
        Provider Claims Codes

        When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        • 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
        • 78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification
        • 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing
        • CPT® Category Ill Code(s) Description Comments
        • 0742T Absolute quantitation of myocardial blood flow (AQMBF), single-photon emission computed tomography (SPECT), with exercise or pharmacologic stress, and at rest, when performed (List separately in addition to code for primary procedure) Not Covered New Code Effective 01/01/2023
        • Meter Code(s) Description Comments

        No code(s) identified

        References

        1. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review (ARCHIVED). Noninvasive testing for coronary artery disease. https://www.ahrq.gov. Published March 2016. Accessed July 12, 2023.
        2. American College of Cardiology (ACC). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. https://www.acc.org. Published January 29, 2013. Accessed July 14, 2023.
        3. American College of Cardiology (ACC). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. https://www.acc.org. Published December 23, 2014. Accessed July 14, 2023.
        4. Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 08/24/2023 Policy Number: HUM-0600-003 Page: 14 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
        5. American College of Cardiology (ACC). 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. https://www.acc.org. Published August 20, 2019. Accessed July 14, 2023.
        6. American College of Cardiology (ACC). 2018 AHA/ACC/AACVPR/AAPA/ABC/ blood cholesterol. https://www.acc.org. Published June 25, 2019. Accessed July 14, 2023.
        7. American College of Cardiology (ACC). 2018 AHA/ACC guideline for the management of adults with congenital heart disease. https://www.acc.org. Published April 2, 2019. Accessed July 14, 2023.
        8. American College of Cardiology (ACC). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. https://www.acc.org. Published September 10, 2019. Accessed August 3, 2023.
        9. American College of Cardiology (ACC). 2020 ACC/AHA guideline for the management of patients with valvular heart disease. https://www.acc.org. Published February 2, 2021. Accessed July 14, 2023.
        10. American College of Cardiology (ACC). 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. https://www.acc.org. Published December 22, 2020. Accessed July 14, 2023.
        11. American College of Cardiology (ACC). 2021 AHA/ACC/ASE/CHEST/SAEM/ SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. https://www.acc.org. Published May 3, 2022. Accessed July 14, 2023.
        12. American College of Cardiology (ACC).
        1. American College of Cardiology (ACC). 2022 AHA/ACC/HFSA guideline for the management of heart failure. https://www.acc.org. Published November 30, 2021. Accessed July 14, 2023.
        2. American College of Cardiology (ACC). 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. https://www.acc.org. Published July 20, 2023. Accessed August 3, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023
        Revision Date: 10/03/2023
        Review Date: 08/24/2023
        Policy Number: HUM-0600-003
        Page: 15 of 21

        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        1. American College of Cardiology (ACC). ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/ SCCT/SCMR/STS 2017 appropriate use criteria for multimodality imaging in valvular heart disease. https://www.acc.org. Published September 26, 2017. Accessed July 14, 2023.
        2. American College of Cardiology (ACC). ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/ SCCT/SCMR/STS 2019 appropriate use criteria for multimodality imaging in the assessment of cardiac structure and function in nonvalvular heart disease. https://www.acc.org. Published February 5, 2019. Accessed July 14, 2023.
        3. American College of Cardiology (ACC). ACC/AHA/ASE/ASNC/ASPC/HRS/SCAI/ SCCT/SCMR/STS 2023 multimodality appropriate use criteria for the detection and risk assessment of chronic coronary disease. https://www.acc.org. Published June 27, 2023. Accessed July 14, 2023.
        4. American College of Cardiology (ACC). ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/ SCMR/SOPE 2020 appropriate use criteria for multimodality imaging during the follow-up care of patients with congenital heart disease. https://www.acc.org. Published February 18, 2020. Accessed July 14, 2023.
        5. American College of Cardiology (ACC). ACCF/ASNC/ACR/AHA/ASE/SCCT/ SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging. https://www.acc.org. Published February 18, 2020. Accessed July 14, 2023.
        6. American College of Cardiology (ACC). ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). https://www.acr.org. Published October 18, 2005. Accessed July 14, 2023.
        7. American College of Radiology (ACR). ACR Appropriateness Criteria. Acute nonspecific chest pain – low probability of coronary artery disease. https://www.acr.org. Published 2020. Accessed July 14, 2023.
        8. American College of Radiology (ACR). ACR Appropriateness Criteria. Asymptomatic patient at risk for coronary artery disease. https://www.acr.org. Published 2020. Accessed July 14, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023
        Revision Date: 10/03/2023
        Review Date: 08/24/2023
        Policy Number: HUM-0600-003
        Page: 16 of 21

        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        1. American College of Radiology (ACR). ACR Appropriateness Criteria. Chest pain – possible acute coronary syndrome. https://www.acr.org. Published 2019. Accessed July 14, 2023.
        2. American College of Radiology (ACR). ACR Appropriateness Criteria. Chronic chest pain – high probability of coronary artery disease. https://www.acr.org. Published 2021. Accessed July 14, 2023.
        3. American College of Radiology (ACR). ACR Appropriateness Criteria. Chronic chest pain – noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. https://www.acr.org. Published 2018. Accessed July 14, 2023.
        4. American College of Radiology (ACR). ACR Appropriateness Criteria. Dyspnea – suspected cardiac origin. https://www.acr.org. Published 2021. Accessed July 14, 2023.
        1. American College of Radiology (ACR). ACR Appropriateness Criteria. Suspected new-onset and known nonacute heart failure. https://www.acr.org. Published 2018. Accessed July 14, 2023.
        2. American College of Radiology (ACR). ACR Appropriateness Criteria. Syncope. https://www.acr.org. Published 2020. Accessed July 14, 2023.
        3. American Heart Association (AHA). ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI expert consensus recommendations for multimodality imaging in cardiac amyloidosis: part 1 of 2 – evidence base and standardized methods of imaging. https://www.heart.org. Published July 2021. Accessed July 14, 2023.
        4. American Society of Nuclear Cardiology (ASNC). Single photon-emission computed tomography (SPECT) myocardial perfusion imaging guidelines: instrumentation, acquisition, processing and interpretation. https://www.asnc.org. Published May 25, 2018. Accessed July 14, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023
        Revision Date: 10/03/2023
        Review Date: 08/24/2023
        Policy Number: HUM-0600-003
        Page: 17 of 21

        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        1. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Single photon emission computed tomography (220.12). https://www.cms.gov. Published October 1, 2002. Accessed July 12, 2023.
        2. ClinicalKey. Balady GJ, Ades PA. Exercise physiology and exercise electrocardiographic testing. In: Libby P, Bonow R, Mann D, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:175-195. https://www.clinicalkey.com. Accessed August 10, 2023.
        3. ClinicalKey. Boden W. Angina pectoris and stable ischemic heart disease. In: Goldman L, Schafer A. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:376- 379.e.1. https://www.clinicalkey.com. Accessed July 12, 2023.
        4. ClinicalKey. Brahmanandam V, Garcia M. Noninvasive evaluation: functional testing, multidetector computed tomography, and stress cardiac MRI. In: Topol E, Tierstein P. Textbook of Interventional Cardiology. 8th ed. Elsevier; 2020:70-89.e4. https://www.clinicalkey.com. Accessed July 12, 2023.
        5. ClinicalKey. Bravo PE, Di Carli MF. Screening for transplant vasculopathy. In: Di Carli, MF. Nuclear Cardiology and Multimodal Cardiovascular Imaging. Elsevier; 2022:307-317. https://www.clinicalkey.com. Accessed July 12, 2023.
        6. ClinicalKey. Case JA, Dekemp RA. Principles of myocardial blood flow quantification with SPECT and PET imaging. In: Di Carli, MF. Nuclear Cardiology and Multimodal Cardiovascular Imaging. Elsevier; 2022:25-36. https://www.clinicalkey.com. Accessed July 12, 2023.
        7. ClinicalKey. Dorbala S, Di Carli MF. Nuclear cardiology. In: Libby P, Bonow R, Mann D, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:277-313. https://www.clinicalkey.com. Accessed July 12, 2023.
        8. ClinicalKey. Goldman, L. Approach to the patient with possible cardiovascular disease. In: Goldman L, Schafer A. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:228-237.e.1. https://www.clinicalkey.com. Accessed July 12, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023
        Revision Date: 10/03/2023
        Review Date: 08/24/2023
        Policy Number: HUM-0600-003
        Page: 18 of 21

        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        1. MCG Health. Myocardial perfusion imaging, exercise stress. 27th edition. https://www.mcg.com. Accessed June 29, 2023.
        2. MCG Health. Myocardial perfusion imaging, pharmacologic stress. 27th edition. https://www.mcg.com. Accessed June 29, 2023.
        3. Merck Manual: Professional Version. Radionuclide imaging of the heart. https://www.merckmanuals.com. Updated September 2022. Accessed July 12, 2023.
        4. Souza AC, Harms HJ, Martell L, et al. Accuracy and reproducibility of myocardial blood flow quantification by single photon emission computed tomography imaging in patients with known or suspected coronary artery disease. Circ Cardiovasc Interv. 2022;15(6):386-397. https://www.ahajournals.org. Accessed July 14, 2023.
        5. UpToDate, Inc. Artifacts in SPECT radionuclide myocardial perfusion imaging. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
        6. UpToDate, Inc. Assessment of myocardial viability by nuclear imaging in coronary heart disease. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
        7. UpToDate, Inc. Cardiac manifestations of systemic sclerosis (scleroderma). https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
        8. UpToDate, Inc. Cardiovascular sequelae of Kawasaki disease: clinical features and evaluation. https://www.uptodate.com. Updated June 2023. Accessed July 12, 2023.
        9. UpToDate, Inc. Hypertriglyceridemia in adults: management. https://www.uptodate.com. Updated July 2023. Accessed August 3, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 08/24/2023 Policy Number: HUM-0600-003 Page: 19 of 21
        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        1. UpToDate, Inc. Noninvasive testing and imaging for diagnosis in patients at low to intermediate risk of acute coronary syndrome. https://www.uptodate.com. Updated June 2023. Accessed July 12, 2023.
        2. UpToDate, Inc. Overview of hypertension in adults.https://www.uptodate.com. Updated July 2023. Accessed August 3, 2023.
        3. UpToDate, Inc. Overview of stress radionuclide myocardial perfusion imaging. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
        4. UpToDate, Inc. Selecting the optimal cardiac stress test. https://www.uptodate.com. Updated June 2023. Accessed July 11, 2023.
        5. UpToDate, Inc. Stress testing for the diagnosis of obstructive coronary heart disease. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.
        6. UpToDate, Inc. Tests to evaluate left ventricular systolic function. https://www.uptodate.com. Updated June 2023. Accessed July 10, 2023.

        Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 08/24/2023 Policy Number: HUM-0600-003 Page: 20 of 21
        Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        with or without albuminuria; not treated with either dialysis or kidney transplantation)

        • Diabetes mellitus
        • Dyslipidemia/abnormal CVD risk biomarkers as evidenced by one or more:
          • Ankle-brachial index of less than 0.97
          • Elevated apolipoprotein B (greater than or equal to 130 mg/dL)
          • Elevated high-sensitivity C-reactive protein (greater than or equal to 2.0 mg/dL)
          • Elevated lipoprotein (a) (greater than or equal to 50 mg/dL or greater than or equal to 125 nmol/L)
          • Persistently elevated (3 determinations) of primary hypertriglyceridemia (greater than or equal to nonfasting)* 150 mg/dL,
        • Erectile dysfunction (without evidence of hormonal deficiency or medication-related side effects)
        • Female with 55 years of age or older, and/or menopausal or premature menopause (less than 40 years of age)
        • History of eclampsia, gestational diabetes or preeclampsia
        • First- or second-degree relative with premature (female 65 years of age or younger, male 55 years of younger) atherosclerotic cardiovascular disease
        • Hypertension (blood pressure that is greater than or equal to 130/80; measured on 2 separate Male 45 years of age or older occasions)*
        • Metabolic syndrome as evidenced by three or more:
          • Elevated blood pressure (systolic 120 to 129 and diastolic less than or equal to 80 mmHg)*
          • Elevated glucose (greater than or equal to 100 mg/dL, fasting)
          • Elevated triglycerides (greater than 150 mg/dL, nonfasting)
          • Increased waist circumference (greater than or equal to 40 inches in a male and greater than or equal to 35 inches in a female)
          • Low HDL-C (less than 40 mg/dL in a male; less than 50 mg/dL in a female)
        • Obesity (body mass index [BMI] greater than or equal to 30 km/m2)
        • Peripheral arterial disease or cerebrovascular disease
        • Previous myocardial infarction

        Low HDL-C (less than 40 mg/dL in a male; less than 50 mg/dL in a female)7 Obesity (body mass index [BMI] greater than or equal to 30 km/m2)12 Peripheral arterial disease or cerebrovascular disease Previous myocardial infarction Previous revascularization (eg, percutaneous coronary intervention or coronary bypass grafting) or medical treatment of coronary artery disease Primary hypercholesterolemia (LDL-C 160-189 mg/dL [4.1-4.8 mmol/L]; non-HDL-C 190-219 mg/dL [4.9-5.6 mmol/L])7 Sedentary lifestyle Sleep disorder (eg, obstructive sleep apnea) South Asian ancestry7 Tobacco use, including electronic nicotine delivery systems (ENDS) (eg, e-cigarettes, vaping) Cardiac Single-Photon Emission Computed Tomography Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 08/24/2023 Policy Number: HUM-0600-003 Page: 21 of 21 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

        Appendix B – Family Relationship
        Family RelationshipDefinition
        First-degreeChild, full-sibling, parent
        Second-degreeAunt, uncle, grandchild, grandparent, half-sibling, niece, nephew
        Third-degreeGreat aunt, great-uncle, great-grandchildren, great-grandparent, half-aunt, half-uncle, first cousin