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Contractor's Policy Number

00-06-R3

Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Title

Myocardial Perfusion Imaging

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply.

CMS National Coverage Policy

• Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
• Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

06/26/2000

Original Policy Ending Date

 Revision Effective Date

06/28/2005

Revision Ending Date

LCD Description

Myocardial perfusion imaging is a non-invasive and safe method of recognizing coronary blood flow and may also be useful in some situations for assessing left ventricular muscle function.

Indications and Limitations of Coverage and/or Medical Necessity

Many different radionuclides are used most often including:

• Technetium-99m tetrofosmin (Myoview ™),
• Technetium-99m sestamibi (Cardiolite™),
• Technetium-99m teboroxime (Cardiotec™), or
• Thallium-201

When these compounds are injected intravenously and a radiation detector is placed over the heart, an image of the heart reflecting relative myocardial perfusion can be generated and electronically, as well as photographically, recorded.

Thallium-201, Tc-99 sestamibi, technetium-99m tetrofosmin, and Tc-99m teboroxime are used to assess myocardial perfusion at rest and during stress testing. Most commonly, there is no evidence of ischemia (diminished blood flow to the myocardium) during the resting state. When stressed, however, evidence of myocardial ischemia may become quite obvious. Usually a standard treadmill exercise tolerance test is used to determine this. However, under certain situations as listed under the clinical indications, standard exercise stress testing is unable to accurately diagnose the presence or absence of myocardial ischemia. Scintigraphic stress testing, utilizing one of these agents, can be utilized in conjunction with stress testing under these cirucmstances. Comparing the scintigraphic imaging associated with the stress test to a rest scintigraphic study, myocardial scarring from prior infarction can be differentiated from exercise-induced ischemia.

When exercise testing is not advisable, or the patient is unable to exercise to a level adequate to stress the heart, Dipyridamole (Persantine™) pharmacologic stress testing (in conjunction with nuclear myocardial perfusion scanning) can be substituted for exercise stress testing. Persantine™ is a potent coronary vasodilator that inhibits the cellular uptake of endogenous adenosine and thus potentiates the vasodilating effects of adenosine, which results in preferential uptake of the scintigraphic agent by the best perfused areas.

The FDA has approved other drugs (e.g., Adenoscan™), that can also be used to accomplish the same goal by increasing the amount of adenosine available to cause coronary dilatation. Single Photon Emission Computed Tomography (SPECT) has been utilized to generate multiple reconstructed images utilizing tomographic techniques, thus allowing images of "slices" of the heart to be imaged in multiple planes.

Clinical Indications for myocardial perfusion include:

• Evaluation for past and recent infarction when there is uncertainty after careful electrocardiographic review,
• Evaluation of patients with suspected angina and non-interpretable EKG changes (examples: caused by drugs, bundle branch block, left ventricular hypertrophy, or intrinsic baseline abnormalities involving the resting EKG),
• Evaluation for acute myocardial infarction in patients with chest pain,
• As part of the decision-making process following coronary angiography, regarding coronary artery bypass surgery or percutaneous transluminal coronary angioplasty,
• Evaluation of the effectiveness of either medical or surgical reperfusion therapy,
• Evaluation of patients with an abnormal resting EKG, unexplained cardiomegaly, syncope, ventricular arrhythmia, or cardiomyopathy where the etiology is suspected to be coronary insufficiency, or;
• Evaluation of myocardial perfusion before vascular surgical procedures (e.g., repair of abdominal aortic aneurysm carotid endarterectomy) may be appropriate if reasonable and necessary for the diagnosis and the treatment of the patient's condition.

CPT/HCPCS Section & Benefit Category

Radiology/Cardiovascular System

Type of Bill Code

11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X

Revenue Codes

32X, 333, 34X, 35X, 40X

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

78460	©	Myocardial perfusion imaging, planar single study
78461	©	Myocardial perfusion imaging, multiple studies, (planar)
78464	©	Myocardial perfusion imaging, tomographic (SPECT), single study
78465	©	Myocardial perfusion imaging, tomographic (SPECT), multiple studies

© CPT American Medical Association

Not Otherwise Classified (NOC)

 ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Covered for:

402.00		Without heart failure
402.01		With heart failure
410.00-410.02		Acute myocardial infarction of the anterolateral wall
410.10-410.12		Acute myocardial infarction of other anterior wall
410.20-410.22		Acute myocardial infarction of inferolateral wall
410.30-410.32		Acute myocardial infarction of inferoposterior wall
410.40-410.42		Acute myocardial infarction of other inferior wall
410.50-410.52		Acute myocardial infarction of other lateral wall
410.60-410.62		Acute myocardial infarction of true posterior wall infarction
410.70-410.72		Acute myocardial infarction of subendocardial infarction
410.80-410.82		Acute myocardial infarction of other specified sites
410.90-410.92		Acute myocardial infarction, unspecified site
411.0-411.1		Other acute and subacute forms of ischemic heart disease
411.81		Coronary occlusion without myocardial infarction
411.89		Other acute and subacute form of ischemic heart disease
413.0-413.1		angina pectoris; decubitus or Prinzmetal
413.9		Other and unspecified angina pectoris
414.00-414.03		Coronary atherosclerosis
414.10		Aneurysm of heart (wall)
414.8		Other specified forms of chronic ischemic heart disease
424.1		Aortic valve disorders
425.0-425.5		Cardiomyopathy
425.7-425.9
426.0		Atrioventricular block, complete
426.2-426.4		Bundle branch block; left hemiblock, right, other
426.50-426.53
427.1		Paroxysmal ventricular tachycardia
427.31		Atrial fibrillation
427.32		Atrial flutter
427.41-427.42		Ventricular fibrillation and flutter
427.69		Premature beats, other
428.0		Congestive heart failure, unspecified
428.1		Left heart failure
428.20		Systolic heart failure, unspecified
428.21		Systolic heart failure, acute
428.22		Systolic heart failure, chronic
428.23		Systolic heart failure, acute or chronic
428.30		Diastolic heart failure, unspecified
428.31		Diastolic heart failure, acute
428.32		Diastolic heart failure, chronic
428.33		Diastolic heart failure, acute or chronic
428.40		Combined systolic and diastolic heart failure, unspecified
428.41		Combined systolic and diastolic heart failure, acute
428.42		Combined systolic and diastolic heart failure, chronic
428.43		Combined systolic and diastolic heart failure, acute or chronic
428.9
429.2		Cardiovascular disease, unspecified
780.2		Syncope and collapse
786.02		Orthopnea
786.09		Symptoms involving respiratory system and other chest symptoms, other
786.50		Chest pain, unspecified
786.51		Precordial chest pain
794.31		Abnormal electrocardiogram
V45.81		Post surgical aortocoronary bypass status
V45.82		Post surgical percutaneous transluminal coronary angioplasty status
V67.00		Follow-up examination, following surgery
V72.81		Pre-operative cardiovascular examination
		Note: Use this diagnosis code only for high-risk patients and high-risk surgeries

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

• The medical record does not verify that the service described by the HCPCS code was provided.
• The service was not documented in the medical record.
• The service was performed for a diagnosis other than those identified under "ICD-9-CM Codes that Support Medical Necessity."
• The service was not medically necessary.
• The service does not follow the guidelines for this policy.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

• To report this service, use the appropriate HCPCS code,
• All of the coverage criteria must be met before this service can be reimbursed by Medicare,
• Diagnosis (es) must be present on any claim submitted, and be coded to the highest level of specificity, and;
• The diagnosis codes(s) must be representative of the patient's condition.

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.

Utilization Guidelines

• If codes 78461 and 78465 are billed on the same date of service, only code 78465 will be reimbursed.
• Medicare will monitor the utilization of this laboratory test through the Medical Review process.

Other Comments

 Sources of Information and Basis for Decision

TrailBlazer Medicare Part B Newsletters: No. 026, June 26, 1998, No. 030, February 10, 1999

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

Revision History

Number		Date		Change
00-06-R3		06/28/2005		Correction of error under "ICD-9 Codes that Support Medical Necessity", incorrect code V67.81 was changed to the correct code of V72.81.
00-06-R2		10/01/2003		HCPCS descriptors shortened.  Spelling error corrected.
00-06-R1		10/01/2002		Annual update of ICD-9 codes for 2003. See bulletin on website for specifics.
				Correction of V67.0 to V67.00

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.