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Humana Cardiac Single-Photon Emission Computed Tomography - Medicare Advantage Form


Cardiac Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI)

Notes: Services that do not meet the criteria listed are not considered medically necessary.

Indications

(974553) Is the patient being assessed for myocardial viability due to significant ischemic ventricular dysfunction and persistent symptoms? 
(974554) Is the patient experiencing heart failure where revascularization would be considered? 
(974555) Does the asymptomatic patient have a coronary calcium Agatston score greater than 400? 
(974556) Is the cardiovascular stress testing, in conjunction with SPECT MPI, not redundant of other tests' expected information? 
(974557) Is the patient being evaluated for chronic ischemic heart disease and for assessment of drug therapy or myocardial viability after revascularization/medical management? 

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Effective Date

01/01/2024

Last Reviewed

NA

Original Document

  Reference



Related Medicare Advantage Medical/Pharmacy Coverage Policies

None

Related Documents

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/Transmittals.

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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.

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Absolute quantitation of myocardial blood flow, an adjunct to cardiac SPECT MPI, is purported to aid in analyzing coronary artery disease.

Coverage Determination

Humana follows the CMS requirement that only allows coverage and payment for services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following:

Cardiac single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) will be considered medically reasonable and necessary when one or more of the following requirements are met:

  • Assessment of myocardial viability in an individual with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms31; OR
  • Heart failure such that revascularization would be considered31; OR
  • Asymptomatic individual with a coronary calcium Agatston score greater than 40031; OR
  • Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests including echocardiography and nuclear cardiac imaging.

However, selection of the test should be made within the context of other testing modalities so that the expected information does not become redundant31; OR

  • Chronic ischemic heart disease; AND one or more:
    1. Assessment of drug therapy29; OR
    2. Assessment of myocardial viability after revascularization or medical management29; OR
    3. Assessment of symptoms suggesting ischemia following coronary artery bypass graft (CABG)29; OR
    4. Assessment of symptoms suggesting restenosis following percutaneous transluminal coronary angioplasty (PTCA)29; OR
    5. Diagnosis of coronary artery disease (CAD), especially in an individual with atypical chest pain29; OR
    6. Evaluation of abnormal or suspected false positive stress electrocardiogram (ECG)29; OR
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  • Evaluation of other symptoms suspicious for the diagnosis of CAD such as syncope and ventricular arrhythmia29; OR
  • Evaluation of suspected or known CAD prior to high risk surgical procedure29; OR
  • Follow up of symptomatic ischemic heart disease29; OR
  • Identification of the presence, location, extent and severity of myocardial ischemia29; OR
  • Planning PTCA to identify lesions causing ischemia, if unknown29; OR
  • Chronic mitral regurgitation in an individual with hypertrophic cardiomyopathy (HCM) when echocardiography is inconclusive or there are poor echocardiograph imaging windows30; OR
  • Congenital heart disease (CHD) - Echocardiography is the method of choice for evaluating an individual with known or suspected CHD; however, an individual may benefit from MPI when assessing for29:
    1. Diagnosis of anomalies of the coronary circulation29; OR
    2. Kawasaki’s disease29; OR
  • Evaluation of an individual in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker32; OR
  • Evaluation of an individual receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin)32; OR
  • Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization and/or coronary angiography are not planned32; OR
  • Evaluation of new, recurrent, or worsening left ventricular dysfunction and/or congestive heart failure30; OR
  • Evaluation of transplant coronary artery disease (TCAD), cardiac allograft vasculopathy (CAV) or ventricular dysfunction in an individual with a history of organ transplantation30; OR
  • Evaluation of ventricular function in an individual with non-ischemic myocardial disease32; OR
  • Individual is experiencing new, recurrent or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms31: AND one or more of the following:
    1. ECG is uninterpretable for ischemia due to one or more of the following31:
      1. A greater than 1 mm ST segment depression (NOT nonspecific ST/T wave changes)31; OR
      2. Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia)31; OR
      3. Individual on digoxin therapy31; OR
      4. Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria)31; OR
      5. Pre-excitation pattern such as Wolff-Parkinson-White31; OR
      6. Ventricular paced rhythm31; OR
    2. Evaluation of chest pain syndrome after revascularization or in an individual with intermediate to high pre-test probability for CAD (eg, Pretest Probability of CAD [CAD Consortium]) regardless of ECG interpretability or ability to exercise31; OR
    3. Evidence or high suspicion of ventricular arrhythmias31; OR
    4. High pre-test probability for CAD (eg, Pretest Probability of CAD [CAD Consortium]) regardless of ECG interpretability or the ability to exercise, and a decision to perform cardiac catheterization or other angiography has not already been made31; OR
    5. History of CAD based on a prior anatomic evaluation of the coronary arteries or a history of CABG or percutaneous coronary intervention (PCI)31; OR
    6. History of false positive exercise stress test (eg, one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD)31; OR
    7. Individual on beta blocker, calcium channel blocker and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study31; OR
    8. Individual with HCM31; OR
    9. Individual with recent equivocal or borderline testing where ischemia remains a concern31; OR
    10. New or previously unrecognized uninterpretable ECG31; OR
    11. Physical inability to perform a maximum exercise workload31; OR
    12. Syncope and collapse (an abrupt, transient, complete loss of consciousness) for an individual with an intermediate or high CHD risk (using ATP III risk criteria) and where cardiac etiology is suspected based on an initial evaluation, including history, physical examination or ECG and individual is unable to exercise31; OR
    13. Worsening or continuing symptoms in an individual who had a normal or submaximal exercise stress test and there is suspicion of a false negative result31; OR
  • Individual will be treated with interleukin 2 products for various malignant disorders31; OR
  • Individual with disease conditions associated with CAD (eg, atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress imaging evaluation performed within the preceding 2 years and are unable to exercise30; OR
  • Individual without cardiac symptoms who underwent a PCI (with stent) procedure more than 2 years prior or a CABG more than 5 years prior and have not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, positron emission tomography [PET] MPI, cardiovascular magnetic resonance [CMR], coronary computed tomography angiography [CCTA], cardiac catheterization) and are unable to exercise30; OR
  • Individual without clear cardiac symptoms in the presence of an elevated cardiac troponin30; OR
  • Individual with recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch on an anatomic imaging study (coronary angiogram or CCTA) may have one stress test with imaging31; OR
  • MPI is appropriate in the evaluation of an acute myocardial infarction and one or more of the following:
    1. Disease severity29; OR
    2. Efficacy of acute reperfusion therapy29; OR
    3. Evidence of myocardial salvage29; OR
    4. Risk assessment and/or prognosis29; OR
    5. Suspected infarction when the combination of history and other tests is not diagnostic29; OR
  • New-onset atrial fibrillation (with no prior cardiac evaluation)30; OR
  • Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within the past year30; OR
  • Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in33:
    1. Individual with intermediate or high likelihood of coronary heart disease33; OR
    2. Individual with minor or intermediate clinical risk predictors (eg, ACS NSQIP calculator) and poor functional capacity33; OR
    3. Individual with poor functional capacity undergoing high risk non-cardiac surgery33; OR
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  • Stress echocardiography for the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting LVOT in an individual with HCM31; OR
  • Stress echocardiography for the evaluation of moderate to severe valvular heart disease, suspected pulmonary artery hypertension, and re-evaluation of exercise-induced pulmonary hypertension to evaluate response to therapy31; OR
  • Unstable angina when MPI is used as an adjunct to aid in the diagnosis or treatment of unstable angina and one or more of the following indications29:
    1. Identification of ischemia in the distribution of a known lesion or in remote areas29; OR
    2. Identification of the severity and/or extent of disease in an individual with medically unstable angina or ongoing ischemia29; OR
    3. Measurement of left ventricular function (LVF)29; OR
  • Utilization of PET MPI in the determination of cardiac involvement using fluorodeoxyglucose (F-18 FDG) to diagnose cardiac sarcoidosis in an individual that is unable to undergo MRI, have inconclusive MRI findings or when high probability of disease exists even after a negative MRI.

Examples of an individual that is unable to undergo MRI include, but are not limited to, an individual with metal implants31; OR

  • Utilization of PET MPI using fluorodeoxyglucose (F-18 FDG) to determine response to immunosuppressive therapy in an individual diagnosed with cardiac sarcoidosis31

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage