Humana Fusion Imaging for Noncancer Indications Form

Description

Fusion imaging combines two different imaging scans to create a more detailed picture for screening or diagnosis than either individual scan. The following are examples of fusion imaging for noncancer indications:

• Positron emission tomography with concurrent computed tomography (PET/CT) – PET assesses the function of tissues and organs by monitoring the metabolic or biochemical activity while tracking the movement and concentration of a radioactive contrast agent. The technique uses special computerized imaging equipment and rings of detectors surrounding the individual to record gamma radiation produced when positrons (positively charged particles) emitted by the radioactive agent collide with electrons. CT combines digital computing with a rotating x-ray device to generate detailed cross-sectional pictures of the imaged body area. Integrated PET/CT imaging is a technique in which both PET and CT are performed during a single visit on a hybrid PET/CT scanner (eg, Biograph mCT). The CT and PET images are then co-registered using fusion software, enabling the physiologic data obtained on PET to be localized according to the anatomic CT images. When PET/CT is performed, a low radiation dose CT without contrast is typically used to keep the radiation dose as low as possible and to limit adverse events. A higher resolution CT requires a higher dose of radiation and intravenous (IV) contrast.
• PET/CT is used in myocardial viability or myocardial perfusion studies to determine problems in the heart such as reduced blood flow or ineffective heart muscle activity. During cardiac testing, the CT provides attenuation correction which clarifies certain small errors in the image. Absolute quantitation of myocardial blood flow is an adjunct to PET myocardial perfusion imaging that aids in analyzing coronary artery disease.
• Neurological uses for PET/CT scanning include evaluation of seizure activity prior to surgery. It is also proposed for diagnosing and distinguishing between Alzheimer’s and other types of dementia. (Refer to Coverage Limitations section)
• Magnetic resonance imaging/computed tomography (MRI/CT) – MRI uses nuclear magnetic resonance to detect atomic nuclei or electron particle energy absorption when exposed to electromagnetic radiation. The images produced are used to diagnose disorders of body structures (eg, soft tissues) that are not easily visualized on standard x-rays. Fusing MRI with CT generates detailed cross-sectional images of the targeted body areas. (Refer to Coverage Limitations section)
• PET/MRI – PET/MRI combines PET functional imaging simultaneously with MRI soft-tissue morphological imaging to reportedly produce enhanced image quality with a reduced radiation dose and prevention of fusion software image mismatch. A PET/MRI using a hybrid imaging system is suggested for imaging anatomical, biochemical and functional characteristics of disease. The Biograph mMR is an example of a PET/MRI device. (Refer to Coverage Limitations section)
• High-definition 3D volumetric imaging (HDVI) – SeeFactor CT3 is a platform that uses HDVI CT, fluoroscopy and digital radiography. It is proposed for diagnostic, interventional and intraoperative imaging of the head, neck, upper spine, upper and lower extremities.⁵¹ (Refer to Coverage Limitations Section)

Fusion Imaging for Noncancer Indications

Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0506-017

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.

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.

Single-photon emission computed tomography with concurrently acquired MRI (SPECT/MRI)

Simultaneous SPECT and MRI images are fused by software which is suggested to provide improved views of anatomical structures. (Refer to Coverage Limitations section)

For information regarding cardiac single-photon emission computed tomography, please refer to Cardiac Single-Photon Emission Computed Tomography Medical Coverage Policy.

For information regarding fusion imaging for cancer indications, please refer to Fusion Imaging for Cancer Indications Medical Coverage Policy.

Coverage Determination

Fusion imaging (eg, PET/CT, MRI DWI/PWI) deemed urgent/emergent (eg, acute coronary syndrome, cardiogenic shock, stroke) are not subject to the criteria within this medical coverage policy.

PET WITH CONCURRENTLY ACQUIRED CT

Cardiac PET/CT Humana members may be eligible under the plan for PET with concurrently acquired CT (PET/CT) for the following indications:

• Cardiac sarcoidosis identification and treatment monitoring^40,41; OR
• Evaluation for cardiac allograft vasculopathy (CAV) in an asymptomatic individual with prior heart transplantation; OR
• Evaluation of nonsustained* or sustained** ventricular tachycardia in a clinically stable individual with intermediate to high risk for CAD (based on the American College of Cardiology [ACC] ASCVD Risk Calculator); OR
• Evaluation of suspected large vessel vasculitis (LVV) (eg, giant cell arteritis, Takayasu arteritis) and/or monitoring of anti-inflammatory treatment response; OR
• Identification of ischemia and assessment of cardiac function with known anomalous coronary artery; OR
• Myocardial perfusion assessment performed at rest or with pharmacologic stress for the diagnosis, medical management and/or risk stratification of cardiac events for an individual with known coronary artery disease when either of the following are met:
  • Following an equivocal cardiac SPECT; OR
  • Performed in place of, but not in addition to, cardiac SPECT with documentation of any of the following:
    • Individual has large breasts with or without implants; OR
    • Individual is incapable of exercise due to physical inability to achieve target heart rate (85% of the maximum predicted heart rate [MPHR]); OR
    • Individual is severely obese (eg, body mass index [BMI] greater than or equal to 35 kg/m2); OR
• Myocardial viability assessment as indicated by either of the following:
  • Cardiac SPECT or stress echocardiogram findings are inconclusive or no viable myocardium identified; OR
  • Known or suspected ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) less than or equal to 35%; OR
• Suspected prosthetic valve endocarditis as indicated by ALL of the following:
  • Clinical suspicion of endocarditis (eg, fatigue, fever, new heart murmur); AND
  • Nondiagnostic echocardiogram results; AND
  • Prosthetic valve implanted 3 or more months prior

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.

Sustained VT lasts greater than 30 seconds or requires termination in less than 30 seconds due to hemodynamic compromise (eg, chest pain, confusion, dyspnea, hypotension).2

Absolute Quantitation of Myocardial Blood Flow

Humana members may be eligible under the Plan for absolute quantitation of myocardial blood flow (AQMBF) as an adjunct to cardiac PET/CT when the criteria for cardiac PET/CT for assessment of myocardial perfusion and/or myocardial viability are met.

Neurologic PET/CT

Humana members may be eligible under the Plan for PET/CT for presurgical evaluation to localize the focus of refractory seizure activity.25

Note: The criteria for PET/CT for refractory seizures are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

Note: The criteria for PET/CT for dementia and myocardial viability are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage PET with Concurrently Acquired CT

Coverage Limitations

PET with Concurrently Acquired CT Humana members may NOT be eligible under the Plan for PET with concurrently acquired CT (PET/CT) for diagnosing or distinguishing between types of dementia or for any other noncancer indications not listed above. This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the following fusion imaging procedures:

• Diagnostic CT scan used in conjunction with PET/CT; OR
• MRI/CT; OR
• PET/MRI; OR
• SeeFactor CT3; OR
• SPECT/MRI

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

Nonconcurrent PET with CT fusion interpretation is considered integral to the primary imaging procedure and not separately reimbursable.

Background

Additional information about cardiovascular disease or neurological disorders may be found from the following websites:

• American College of Radiology
• National Library of Medicine

Alternatives to MRI/CT, PET/CT, PET/MRI, SPECT/MRI include, but may not be limited to, the following:

Medical Alternatives

• Conventional CT
• Conventional MRI
• Conventional PET
• Conventional SPECT
• Radiography

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