Evicore Cardiac Imaging Guidelines

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CLINICAL GUIDELINES Cardiac Imaging Policy Version 1.0 Effective February 14, 2020

eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight.

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Cardiac Imaging Guidelines Abbreviations for Cardiac Imaging Guidelines ...... 3 Glossary ...... 4 CD-1: General Guidelines ...... 5 CD-2: Echocardiography (ECHO) ...... 15 CD-3: Nuclear Cardiac Imaging ...... 27 CD-4: Cardiac CT, Coronary CTA, and CT for Coronary Calcium(CAC) ...... 34 CD-5: Cardiac MRI ...... 42 CD-6: Cardiac PET ...... 47 CD-7: Diagnostic Heart Catheterization ...... 50 CD-8: Pulmonary Artery and Vein Imaging ...... 57 CD-9: Congestive Heart Failure ...... 60 CD-10: Cardiac Trauma ...... 63 CD-11: Adult Congenital Heart Disease ...... 65 CD-12: Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD) ...... 86 CD-13: Pre-Surgical Cardiac Testing ...... 88

Abbreviations for Cardiac Imaging Guidelines ACC American College of Cardiology ACS acute coronary syndrome AHA American Heart Association ASCOT Anglo-Scandinavian Cardiac Outcomes Trial ASD atrial septal defect BMI body mass index CABG coronary artery bypass grafting CAD coronary artery disease CHF congestive heart failure COPD chronic obstructive pulmonary disease CT computed tomography CCTA coronary computed tomography angiography CTA computed tomography angiography EBCT electron beam computed tomography ECP external counterpulsation (also known as EECP) ECG electrocardiogram ECP external counterpulsation ETT exercise treadmill stress test Fluorodeoxyglucose,a radiopharmaceutical used to measure myocardial FDG metabolism HCM hypertrophic cardiomyopathy IV intravenous LAD left anterior descending coronary artery LDL-C low density lipoprotein cholesterol LHC left heart catheterization LV left ventricle LVEF left ventricular ejection fraction MI myocardial infarction MPI myocardial perfusion imaging (SPECT study, nuclear cardiac study) MRA magnetic resonance angiography MRI magnetic resonance imaging millisievert (a unit of radiation exposure) equal to an effective dose of a joule of mSv energy per kilogram of recipient mass MUGA multi gated acquisition scan of the cardiac blood pool percutaneous coronary intervention (includes percutaneous coronary PCI angioplasty (PTCA) and coronary artery stenting) PET positron emission tomography PTCA percutaneous coronary angioplasty RHC right heart catheterization SPECT single photon emission computed tomography TEE transesophageal echocardiogram TIA Transient Ischemic Attack VSD ventricular septal defect Cardiac Imaging

Glossary Agatston Score: a nationally recognized calcium score for the coronary arteries based on Hounsfield units and size (area) of the coronary calcium Angina: principally chest discomfort, exertional (or with emotional stress) and relieved by rest or nitroglycerine Anginal variants or equivalents: a manifestation of myocardial ischemia which is perceived by patients to be (otherwise unexplained) dyspnea, unusual fatigue, more often seen in women and may be unassociated with chest pain ARVD/ARVC – Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy: a potentially lethal inherited disease with syncope and rhythm disturbances, including sudden death, as presenting manifestations BNP: B-type natriuretic peptide, blood test used to diagnose and track heart failure (n-T-pro- BNP is a variant of this test) Brugada Syndrome: an electrocardiographic pattern that is unique and might be a marker for significant life-threatening dysrhythmias Double Product (Rate Pressure Product): an index of cardiac oxygen consumption, is the systolic blood pressure times heart rate, generally calculated at peak exercise; over 25000 means an adequate stress load was performed Fabry’s Disease: an infiltrative cardiomyopathy, can cause heart failure and arrhythmias Hibernating myocardium: viable but poorly functioning or non-functioning myocardium which likely could benefit from intervention to improve myocardial blood supply Optimized Medical Therapy should include (where tolerated): antiplatelet agents, calcium channel antagonists, partial fatty acid oxidase inhibitors (e.g. ranolazine), statins, short-acting nitrates as needed, long-acting nitrates up to 6 months after an acute coronary syndrome episode, beta blocker drugs (optional), angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blocking (ARB) agents (optional) Platypnea: shortness of breath when upright or seated (the opposite of orthopnea) and can indicate cardiac malformations, shunt or tumor Silent ischemia: cardiac ischemia discovered by testing only and not presenting as a syndrome or symptoms Syncope: loss of consciousness; near-syncope is not syncope Takotsubo cardiomyopathy: apical dyskinesis oftentimes associated with extreme stress and usually thought to be reversible Troponin: a marker for ischemic injury, primarily cardiac Cardiac Imaging

CD-1: General Guidelines CD-1.1: General Issues – Cardiac 6 CD-1.2: Stress Testing without Imaging – Procedures 8 CD-1.3: Stress Testing with Imaging – Procedures 8 CD-1.4: Stress Testing with Imaging – Indications 8 CD-1.5: Stress Testing with Imaging – Preoperative 10 CD-1.6: Transplant Patients 11 CD-1.7: Non-imaging Heart Function and Cardiac Shunt Imaging 12 CD-1.8: Genetic lab testing in the evaluation of CAD 12 CD-1.9: CAD Risk factor modification 12

______©2019 eviCore healthcare. All Rights Reserved. Page 5 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  General Issues CD-1.1: Cardiac © NH3 Rubidium Chest x Chest andpelvis Abdomen of CT ) gating prospective (with (CTCA) angiography coronary tomography Computed (cath) angiogram coronary conventional Diagnostic (MPI) study perfusion myocardial Thallium myocar PET (MPI) study perfusion myocardial Sestamibi Imaging Study 2019 Practice Estimate of Effective Radiation Dose chart for Selected     advanc A current clinical evaluation (within 60 days) is required prior to considering already been made, there is often no need for imaging stress testing. decisions. If a decision to perform cardiac catheterization or other angiography has Cardiac imaging is not indicated if the results will not affect patient management

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Vital signs, height   o Assessment management Advanced imaging should answer aclinical question which will affect   x chest and non- Relevant history and physical examination and appropriate laboratory studies GuidelinesImaging -

ray established patient can substitute Other meaningfulcontact  Typical angina (definite): Most recent previous stress testing and its findings or Effort should be made to obtain copies of reported “abnormal” ECG studies in ed imaging, which includes:

dial perfusion study: perfusion dial - der to determine whether the ECG is uninterpretable 82    present: Angina pectoris is classified as typical when all of the following are -

ray or ECHO/ultrasound, after symptoms started or worsened. advanced imaging modalities, such as recent ECG (within 60 R B heaviness, burning, or tightnes Substernal chest discomfort (generally described as pressure, rought on by exertion or emotional stress elieved by rest

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59 49 pattern in an individual with ahistory of CABG or PCI  Anginal equivalents: Anginal equivalents: the typical angina characteristics.   Non o lacks (probable): angina Atypical

Test Probability of CAD by Age, Gender, and Symptoms and Gender, Age, CAD by of Probability Test

The Pre The required (location within the chest is not required). Pre and relieved with rest, experiencing chest pain that is "exertional" or "due to emotional stress" When clinical information is received indicating that a patient is May radiate to the left arm or jaw testing with imaging using the Pre- symptoms. All factors must be considered in order to approve stressfor - anginal chest pain: chest anginal Greater thanGreater 90% pre Less than 5%Less pre- Between and10% 5% pre- Between and90% 10% - pre Gender Women Women Women Women - ne of the characteristics of definite or typical angina. Test Probability Grid. N Men Men Men Men - . All All .

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CD-1.2: Stress Testing without Imaging – Procedures

The Exercise Treadmill Test (ETT) is without imaging.  Necessary components of an ETT include:  ECG that can be interpreted for ischemia.  Patient capable of exercise on a treadmill or similar device (generally at 4 METs or greater; see functional capacity below).  An abnormal ETT (exercise treadmill test) includes any one of the following:  ST segment depression (usually described as horizontal or downsloping, greater or equal to 1.0 mm below baseline)  Development of chest pain  Significant arrhythmia (especially ventricular arrhythmia)  Hypotension during exercise  Functional capacity greater than or equal to 4 METs equates to the following:  Can walk four blocks without stopping  Can walk up a hill  Can climb one flight of stairs without stopping  Can perform heavy work around the house

Practice Note An observational study found that, compared with the Duke Activity Status Index, subjective assessment by clinicians generally underestimated exercise capacity see reference 25.

CD-1.3: Stress Testing with Imaging – Procedures  Imaging Stress Tests include any one of the following:  Stress Echocardiography see CD-2.6: Stress Echocardiography (Stress Echo) – Coding  MPI see CD-3.1: Myocardial Perfusion Imaging (MPI) – Coding  Stress perfusion MRI see CD-5.3: Cardiac MRI – Indications for Stress MRI  Stress testing with imaging can be performed with maximal exercise or chemical stress (adenosine, dipyridamole, dobutamine, or regadenoson) and does not alter the CPT® codes used to report these studies.

CD-1.4: Stress Testing with Imaging – Indications  Stress echo, MPI or stress MRI, can be considered if there are new, recurrent, or worsening cardiac symptoms and any of the following:  High pretest probability (greater than 90% probability of CAD) per Table 1  A history of CAD based on:  A prior anatomic evaluation of the coronaries OR  A history of CABG or PCI  Evidence or high suspicion of ventricular tachycardia Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 8 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Cardiac © 2019  theof following: Stress echo, MPI or stress MRI, can be considered regardless of symptoms any for        

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Within 3monthsan of acutecoronary syndrome (e.g.   Inadequate ETT: an adequate workload for adiagnostic exercise study. cha Heart rate less than 50 bpm in patients, including those ischemia remains a concern, regardless of symptoms. Patients with recent equivocal, borderline, or abnormal stress testingwhere treadmill test and there Continuing symptoms in a patient who had a normal or submaximal exercise        ECG is uninterpretable for ischemia due to any oneof the following: controlled. 180mmhg, if provider feels strongly that CAD needs evaluation prior to BP being Poorly controlled hypertension defined as systolic BP greater than or equal to Coronary calcium score ≥ Age    the most recent acute coronary event apply: be performed to evaluate for inducible ischemia if all of the following related to [STEMI], unstable angina, non- GuidelinesImaging

macrov is abnormal however the abnormality does not appear to be due to History of false positive exercise treadmill test: a false positive ETT is one that estimated is MPHR (MPHR). heart rate is calculated as 8 Physical inability to achieve target heart rate (85% MPHR or 220- Patient on digitalis preparation lead V1 and V2 are not included). AVF waveT inversion in the inferior and/or lateral leads. This incl without repolarization abnormalities or by voltage criteria) LVH with repolarization abnormalities, wave changes) Greater or equal to 1.0 mm Pre Ventricular pacedrhythm ischemia) branch and left anterior hemiblock does not render ECG uninterpretable for Complete LeftBundle Branch Block( episode of symptoms No prior coronary angiography or imaging stress test since No recurrent chest pain symptoms and nosigns of heart failure Individual nnel blocker 40 - excitation , V5 or V6. (T wave inversion isolated in lead III or T wave inversion in years or greater andknown diabetes mellitus

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  need preoperative for cardiactesting. moderate- Is the surgery considered high, moderate or low risk? (see Table   surgery? Would the patient qualify imagingfor stress testing independent of planned significance, can have one stress test with imaging. coronary stenosis in a major coronary branch, which is of uncertain functional Prior anatomic imaging study (coronary angiogram or CCTA) demonstrating propafenone) and annuallywhile taking the medicatio n. To assess for CAD prior to starting aClass IC antiarrhythmic agent (flecainide or imaging portion of a stress test but not on the ECG portion. Every 2years there if was documentation of previous “silent ischemia” onthe One routine study at 5 years or more after CABG, without cardiac symptoms.  One routine study 2years or more after a stent Patient with an elevated cardiac troponin.   Asymptomatic patient with anuninterpretable ECG that: Unheralded syncope (not near syncope)  heart failure such that revascularization would beconsidered. dysfunction (suspected hibernating myocardium) and persistent symptoms or Assessing myocardial viability in patients with significant ischemic ventricular  GuidelinesImaging – –

Imaging the EKG since the last stress test. unless the patient has developed new cardiac symptoms or a new change in ETT per guidelines if there has not been an imaging stress test within 1year* Surgery Intermediate since thelastEKG stress test. the patient has developed new cardiac symptoms or a new change in the stress test if there has not been an imaging stress test within 1year Risk High If no, go to step 2 If yes, proceed to stress testing guidelines; Except I H viabilitywithout accompanying PET metabolism information. Note: examinations PET and MPI perfusion studies are usually accompanied by PET metabolic assess myocardial viability depending on physician preference. s anew uninterpretable change. as never been evaluated or

steps that determine the need for imaging stress testing in (stable) pre-

MRI, cardiac PET, MPI PET, cardiac MRI, risk, proceed below. low If with aleft main stent where it can be done at 1year. for additionalfor indications s:

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 vasculopathy or new symptoms. supported more often than every other year without evidence for progressive After two consecutive normal imaging stress tests, repeated testing is not prior cardiac imaging study if there is evidence of progressive vasculopathy. be repeated annually after transplant for at least two years or within oneyear of a at one year, 32% at five years and 53% at ten years. An imaging stress test can ischemic heart disease secondary to their medication. Risk of vasculopathy is 7% Individuals who have undergone organ transplant are at increased risk for MPI) prior to transplant. transplant can undergo imaging stress testing every year (usually stress echo or Individuals who are candidates for any type of organ       surgery) Clinical Risk Factors (for cardiac death & non GuidelinesImaging

Low Risk Low Cre Diabetes Mellitus History previous of TIA or stroke ray showing heart failure) failure, previous pulmonary edema, third heart sound, bilateral rales, chest x History compensated of previous congestive heart failure (history of heart use of nitroglycerin, typical angina, ECG Q waves, previous PCI or CABG) History ischemic of heart disease (previous MI, previous positive stress test, vascular surgery) Planned atinine level > 2mg/dL high

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400  ______ modification factor Risk CAD CD-1.9:  CD-1.   CD-1.  Cardiac © 2019 cardiac shunt imaging study described by CPT Echocardiogram should not be performed in lieu of other preferred modalities.   modification factor Risk guidelines Corus the non- MRI, cardiac CT, or cardiac PET depending on the clinical situation, rather than by Ejection fraction can be obtained by echocardiogram, MPI, MUGA study, cardiac Procedures reported with CPT  Post-C 

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 PCSK9 drugs are a new addition to the treatment of hyperlipidemia reduction with an abundance of scientific evidence regarding their efficacy. Statins remain the     theOne of followingimaging studies maybe performed annually: consideration. Stress testing after five years may proceed according to normal patterns of 8: Non-imaging 7: GuidelinesImaging

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Cardiac Imaging 10. 11. 6. 5. 4. 9. 8. 7. 3. 2. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Peters 12. 1. References Cardiac 13. 15. 14. 16. 17. 18. © 2019 d - 106(10):1423 Nov: 2010 Cardiol J Am scintigraphy. perfusion myocardial undergoing patients in test treadmill minute anine of value Prognostic al. et AJ, James F, Hutchings AJ, Marshall . 00001 Stable Angina Pectoris. Pectoris. Angina Stable Chronic Roundtable: Editor’s The Roberts WC. GW, Vetrovec CJ, Pepine SB, King VE, Friedewald Patients of andManagement Evaluation Cardiovascular Perioperative on Guideline ACC/AHA 2014 al. et AD, Auerbach KE, Fleischmann LA, Fleisher . doi:10.1016/j.jacc.2015.09.011 Pain. Chest With Patients Department Emergency in Imaging Cardiovascular of Utilization Appropriate ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Rybicki FJ, Udelson JE,Peacock the American College of Cardiology of College American the Jul 1; Jul 2008 Spotlight, Cardiosource in women? work test treadmill the Does RS. Blumenthal and JH Mieres 21 147:8 2007; Med Ann Intern electrocardiogram. a normal and disease artery coronary suspected with patients in testing treadmill exercise after - long predicting for model validated An externally al. et DJ, Magid CE, Pothier MS, Lauer Clin hospitalizations. cardiac future predicts test treadmill on exercise pain Chest PN. Peterson JS, Rumsfeld PM, Ho Cardio 2002; 40: 2002; Cardio Coll Am J Guidelines). Testing Exercise 1997 the Update to (Committee Guidelines Practice on Force Task Association Heart Cardiology/American of College American the of A report Article. Summary Testing Exercise for Update Guideline 2002 ACC/AHA al. et JT, Bricker GJ, Balady RJ, Gibbons doi:10.1016/j.amjcard.2007.09.001. - doi:10.7326/0003 2012;157(10):729. Surgeons. Thoracic of Association/Society Nurses Cardiovascular Foundation/American Heart Foundation/American Cardiology of College Physicians/American of College American the From Guideline Practice Clinical a of Summary Disease: Heart Ischemic Stable of Diagnosis A. S, al et SD, Williams A, Fihn Qaseem Circulation Summary. Executive Disease: Heart Ischemic Stable With Patients of Management and Diagnosis the for Guideline ACCF/AHA/ACP/AATS/PCNA/SCAI/STS al. et 2012 J, Abrams JM, Gardin SD, Fihn The American Journal of Cardiology of Journal American The All and Death Sudden to Test Exercise During Parameters Rate Heart of Relation JD. Neaton HE, Bloomfield RS, Crow RJ, Prineas GA, Grandits AS, Adabag . doi:10.1001/archinternmed.2007.68 Med Intern Arch testing. exercise for referred patients in events cardiac stress echocardiography stress et J, Brown E, E, Pasanisi Picano – 22:895 2001; Journal Heart European angiography? coronary annual need recipients transplant heart Do U. Sechtem - 120:86 2009; Circulation Association. Heart the American from advisory a science surgery: undergoing patients obese severely of and management evaluation Cardiovascular al. et LA, Fleisher MA, P, Alpert Poirier Clin echocardiography. exercise of use based false the of S. search In Schaefer L, Baker J, Southard - 119:907 2001; Chest ECG. the on emphasis with concepts Current evaluation: cardiac in testing Stress ME. Tavel - 26(8):769 August; 2007 Transplantation: Twenty Transplantation: Tayl . oi:10.1016/j.amjcard.2010.06.074

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Journal of the American College of Cardiology of College American the of Journal CS2 on PN, Magid DJ, Ross C, et al. Association of exercise capacity on treadmill with future with on treadmill capacity exercise of Association al. et C, Ross DJ, Magid PN, on - - 2012;126(25):3097 . CS4 925. doi: 925. . 531- . https://www.medscape.com/viewarticle/578141_3 - 30:505 2007; Cardiol 1540 . All All . . 897

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Journal of Journal Surgery. Noncardiac Undergoing . doi:10.1016/j.amjcard.2008.01.021 1443. - Cause Mortality in Asymptomatic Men. Asymptomatic in Mortality Cause - 10.7326/0003 8924 - 2007;100(11):1635 . . 10.1016/j.ahj.2007.04.032 . 00010 . —2007. . Medicine of Internal Annals 40.doi:10.1002/clc.20174/abstract 879. . - 168(2):174 2008; . - 4819

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Cardiac 20. 27. 26. 25. 24. 23. 22. 21. 28. 19. © 2019 Society forCardiovascularMagneticRes Cardiovascular AngiographyandInterventions,SocietyofCardiovascularomputedTomography, 2013 Multi-m doi:10.1016/S0735-1 2016;57(10):1654-1 on theClinicalIndicationsforMyocardialPerfus Nuclear Cardiology Cardiology. June2017.doi.org/10.1007/s12350-0 ischemic heartdisease—state-o doi:10.1001/jamainternmed.2014.2914. preoperativ doi:10.1016/j.echo.2010.12.008. Endorsed bytheAmericanCollegeofChestPhysic Cardiovascular ComputedTomography,andSocietyforardiovascularMagneticRes Criteria TaskForce,AmericanSoc Echocardiography. AReportoftheAmericanCollegeCardiologyFoundationAppropriateUse ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011AppropriateUseCriteriafor Echocardiography, AmericanHeartAss Circulation. 2014;130(4):350.doi:10.1161/CIR.0000000000000061. Suspected IschemicHeartD on CardiovascularRadiology.RoleofNoninvasiveTestingintheClinicalEvaluation the CouncilonClinicalCardiology,ardiovascularImagingandInterventiCommitteeof doi:10.1016/j.jacr.2017.08.046. Valve Replacement.JournaloftheAmericanCollegeRadiology.2017;14(11). 269(3). doi:10.1148/radiol.13120696. 2014; 63:forthc Nuclear Cardiology,HeartFailureSocietyofAmerica,RhythmSociety Task Forc heart disease:areportoftheAmericanCollegeCardiologyFoundation,AppropriateUs Medicine. 2018;168(9):640.doi:10.7326/m18-0 the AmericanDiabetesAssociationStandardsofMedicalCareinDiabetes2018.AnnalsInternal Cardiovascular AngiographyandInterventions,SocietyofCriticalCareMedicine,Soc Society ofNuclearCardiology,HeartFailureAmerica,HeartRhythmSociety,ocietyfor Wolk MJ,BaileySR,D Chamberlain JJ,ohnsonEL,LealS,etal.Cardiov Taqueti V,DorbalaS,Wolinsky.Myocardialperfusionimaginginwomenfortheev Melon CC,EshtiaghiP,LuksunWJ American CollegeofCardiologyFoundationAppropriateUs Mieres JH,GulatiM,BaireyMerzN,etal. Leipsic J Blank P,ScheopfUJ,LeipsicJA.CTintranscatheteraorticvalvereplacement.Radiology,2013; Bateman TM,DilsizianV,BeanlandsRS,epueyEG,HellerGWolinskyA.AmericanSociety Diamond GA.Aclinic

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GuidelinesImaging A, BlankeP,HanleyM,etal.ACRppropriatenessCriteria e, AmericanHeartssoc e exercisecapacity.JAMAInternMed2014;174:1507. odality oming. doi:10.1016/j.jacc.2013.11.009 andSoc appropriateusecriteriaforthedetec 656. doi:10.2967/jnumed.116.180448 097(83)80093-X. ally relevantclassificationof . All All . oherty J

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CD-2: Echocardiography (ECHO) CD-2.1: Transthoracic Echocardiography (TTE) – Coding 16 CD-2.2: Transthoracic Echocardiography (TTE) – Indications 17 CD-2.3: Frequency of Echocardiography Testing 20 CD-2.4: Transesophageal Echocardiography (TEE) – Coding 21 CD-2.5: Transesophageal Echocardiography (TEE) – Indications 22 CD-2.6: Stress Echocardiography (Stress Echo) – Coding 23 CD-2.7: Stress Echocardiography–Indications, other than ruling out CAD 23 CD-2.8: 3D Echocardiography – Coding 24 CD-2.9: 3D Echocardiography – Indications 24 CD-2.10: Myocardial strain imaging (CPT® 0399T) 24 CD-2.11: Myocardial contrast perfusion echocardiography (CPT® 0439T) 24

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CPT not GuidelinesImaging 93320 and CPT .

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93306 includes the Doppler exams, so CPT - - - mode, follow mode, mode, Dopplerwithout or color flow mode, andcolorDoppler complete flow, dial contrast perfusiondial at or echocardiography, contrast rest with Transthoracic Echocardiography Transthoracic Echocardiography Transthoracic TTE withTTE 2 withTTE 2 complete withTTE 2 limited TT TTE congenitalfor cardiac anomalies, complete Doppler Echocardiography Doppler ® . All All . E congenitalfor cardiac anomalies, follow

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up or limited up or - - - D, M D, M D, M D, Investigational Codes Investigational - - - mode, follow mode, mode, Dopplerwithout or color flow color flow, and Doppler mode, TTE CODES TTE diography (TTE) – (TTE) diography

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ –Indications (TTE) Echocardiography Transthoracic CD-2.2:       Practice Note s    Cardiac  © 2019  canTTE beperformedthefor following: CPT 3D CPT completed to ensure proper claims submission. Depending upon individual health plan payer contracts, post CPT 2- If no congenital issue is discovered, then CPT include Doppler and color flow mapping. codes If acongenital issue is found on the initial echo, acomplete echo is reported with codes they will bereporting until the initial study is completed Providers performing echo on a pediatric patient, may not knowwhat procedure     Dopplerecho maybe usedevaluation for the of following:    “evaluate or document the attempt to evaluate” all of the required structures. Limited For a2D transthoracic echocardiogram without Doppler, report CPT  time of thetime of pre- Since providers may not know the appropriate code/s that will bereported at the

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Doppler is included in the study. included in the study. CPT procedure. (as denoted by the + sign) andare assigned in addition to code thefor primary    Newworsening or cardiac Shunt detection Known or suspected hypertrophic obstructive cardiomyopathy Known or suspected valvular disease Shortness of breath A limited congenital transthoracic echocardiogram is reported with CPT CPT A limited transthoracic echocardiogram is reported with CPT Doppler codes (CPT rendering of MRI and CT studi GuidelinesImaging ® ® ®

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 Syncope  Heart failure  Murmur  Hypertension – can be done once with initial evaluation  New signs or symptoms of cerebral ischemia or peripheral embolic event  Valve function and structure:  History and/or physical examination suggesting significant valvular disorder  Valve Surgery  If valve surgery is being considered can have TTE twice a year  Post-surgery at 6 weeks to establish baseline, then one routine study (surveillance) 3 years or more after valve surgery (repair or prosthetic valve implantation).  TAVR follow-up is indicated at, 1 month, and at one year post-procedure and annually thereafter.  A baseline post-op TTE is usually performed within one week after surgery. This baseline study may also be approved as an outpatient if not performed in the hospital prior to discharge  See: CD 4.8: Transcatheter Aortic Valve Replacement (TAVR)  Mitral valve clip follow-up may be approved at 1 month, at 6 months, and at one year post-procedure  Ventricular function assessment including, but not limited to the following:  Chemotherapy induced cardiomyopathy see: CD-12.1: Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD)  Post myocardial infarction can be done once in follow-up. This should not be done less than 6 weeks post MI  Evaluation prior to ICD/CRT placement, if baseline has not been established  Cardiac structure: an echocardiogram can be done to assess cardiac structure when there are new or worsening cardiac signs or symptoms, suggesting disorders such as, but not limited to:  Infiltrative diseases (e.g. sarcoid, amyloid)  Ventricular septal defect (VSD)  Papillary muscle rupture/dysfunction  Hypertrophy including:  asymmetric septal hypertrophy  spade heart

 hypertensive concentric hypertrophy  infiltrative hypertrophy  pacemaker insertion complication  pericardial effusion  cardiac injury due to blunt chest trauma  Cardiac Defects or Masses  Embolic source in patients with recent Transient Ischemic Attack (TIA), stroke, or peripheral vascular emboli as an initial study before TEE.  ASD repair or VSD repair: Cardiac Imaging

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   Patients with BAVs and no demonstrable aortopathy may PVD Thoracicaortic aneurysm/dissection New abnormality on an EKG that has not been evaluated    (HCM) Screening first for Pacemaker insertion complication    Inflammatory yearswithTTEthe for developmentof aortic enlargement  GuidelinesImaging

  Evaluation of Clot detection Tumor evaluation  for HCM by 2D   Congenital Heart Disease  pressure response during maximal upright exercise. evaluated every 12to 18 months with 2D Affected individuals identified through family screening or otherwise should be involved in particularlyintense competitive sports. younger than age 12 unless there is a high- Systematic screening is usually not indicated for first ECG every five years to screen for delayed adult First    Endocarditis including: Congenitalheart disease Pericardial effusion/pericardial disease including pericardial cysts F

- irst 6.8 disease that predisposes to Screening of the ascending aorta in known or suspected connective tiss Also syndrome, hereditary forms of ascending aortopathy first Incomplete septal defect repair may be followed yearly Screening the for presence of bicuspid without achange in clinical status. following incomplete or palliative repair, with residual abnormality and Routine yearly surveillance of adult congenital heart disease is allowed Within the firstyear of surgery A A P Fever Dietz) CoronaryArtery Dissection (SCAD)/Ehlers- Aneurysm Syndromes/Spontaneous (Familial Disorders tissue - - ositive blood cultures indicating bacteremia or degree relatives who are 12 to 18 years old should be screened yearly degree relatives who are older than age 18should have 2D : : new murmur Aortic Dissection - degree relatives of patients with bicuspid see see

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S heart failureortoev ( Hypertrophic cardiomyopathy prolapse, regardless of extent Significant valve deformity, such as thickened stenosis Significant valve dysfunction, including moderate or severe regurgitation or Prosthetic heart valve Mild aortic or mitral stenosis Bicuspid aorticvalve A A Prosthetic valve dysfunction or thrombosis Decompression illness Stroke/transient ischemic attack Pericardial disease      Congestive heart failure (new or worsening) Myocardial infarction or acute coronary syndrome Cardiac murmurs GuidelinesImaging TTE) – tenosis history of prior cardiac transplant, per transplant center protocol E E P Ortho New symptoms of dyspnea , , levated BNP dema aroxysmalnocturnal dyspnea perative aorticrootdilatationseeCD11.2.9CongenitalValvularAortic without regard thefor

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  CD-2.4: Cardiac © 93318 93315 93312 CPT CPTcodes: echo, if*Doppler performed, may bereported separately in add echo,Doppler color velocityflow mapping study echo,Doppler pulsed wave spectral display, and/or follow D Echocardiography* Doppler on anfunction immediate time basis purposes,TEE monitoring for ongoing assessment of cardiac pumping only anomalies,TEE congenital for acquisition, interpretation image and report anomalies,TEE congenital for probe only placement interpretation acquisition, anomaliesTEE congenital for 2 with imageTEE acquisition,and interpretation, report only probe placementTEE only and with 2 TEE Echocardiography Transesophageal 2019 oppler echo, pulsed waveoppler spectral display and/or  physician cannot bill globally. professional services if the test is performed in a hospital or other facilitywhere the assi Physicians   CPT (transducer) placement and (2) image acquisition/interpretation, is reported with The intervals. mit mild or thickened, myxomatous appearing mitral valve with bi does not generally require routine echocardiographic follow with

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______        CD-2.5:   Cardiac © 2019   such as the following: documentation of the way in which repeat studies will affect patient management Repeat studiesTEE are based upon findings in the original study and Prior to planned atrial fibrillation ablation/pulmonary vein isolation procedure. Assessing leftfor atrial thrombus prior to cardioversion of atrial fibrillation.   Embolic events when there is an abnormal TTE or a history of atrial fibrillation  Embolic source or intracardiac shunting when TTE is inconclusive Pre inadequate Assessing valvular dysfunction, especially mitral regurgitation, when TTE is Limited transthoracic echo window Moni service). Hospitals should report TEE procedures using CPT 

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  provided, CPT See also Left Atrial appendage Closure device (   Cardiac valve dysfunction that other imaging studies have provided Clarify atria/atrial appendage, aorta, mitral/aortic valve beyond the information t aortic cholesterol plaques, thrombus in cardiac chambers, valve vegetation, Examples CPT - GuidelinesImaging umor umor operati

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atrial septal defect, ventricular septal defect, patent foramen ovale, 13.5: ® . All All . 93312 isreported.

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  CAD Echocardiography Stress CD-2.7: StressCD-2.6: Echocardiography (Stress Echo) – Cardiac © addition to to addition the primary SE codes: echo*Doppler ( * echo,Doppler color velocityflow mapping echo,Doppler pulsed wave spectral display, and/or follow echo,Doppler pulsed wave spectral display and/or Echocardiography Doppler continuous electrocardiographicof monitoring, physician with supervision pharmacologically and/or test with: report induced stress, with includesEcho, (2D), transthoracic, M pharmacologically and/or test with induced stress, with includesEcho, (2D), transthoracic, M Echocardiography Stress 2019 CPT 93351 93350 CPT the stress echo code. 93325)are necessary In general spectral Doppler (CPT      evaluation of CAD, stress echo can be used to evaluate the following conditions: See:

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 Hypertrophic cardiomyopathy P Valvularheart disease R Dyspnea on exertion (specifically to evaluate pulmonary hypertension) and/or prognostic information or interventional decision GuidelinesImaging ® 93350 and

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CPT Guidance Mitral valve anatomy specifically related to mitral valve stenosis cardiotoxic chemotherapy) are needed for treatment decision (e.g. implantation of ICD, alteration in Left ventricular volume andejection fraction assessment CPT echocardiography workstation, is the most common code used for 3D rendering done with GuidelinesImaging

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Cardiac Imaging 10. 9. 11. 12. 8. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 7. 6. 5. 2. ______4. 1. References Cardiac 3. 13. © 2019 The Annals of Thoracic Surgery Thoracic of Annals The Replacement. Valve Aortic Transcatheter doi:10.1016/j.jacc.2013.11.009. y Cardiolog of College American the of Journal Disease. Heart Ischemic Stable of Assessment Risk and Detection the for Criteria Use Appropriate Multimodality 2013 Echocardiography of Society American of the Journal Ultrasound. Doppler and Echocardiography With Valves Prosthetic of Evaluation for Recommendations al. et JG, Dumesnil JB, Chambers WA, Zoghbi doi:10.1016/j.athoracsur.2012.01.084. Echocardiography of Society American the of Journal Echocardiography. of Society American the from Report A Adults: in Heart Right the of Assessment Echocardiographic the for Guidelines al. et J, Afilalo Lai LG, WW, Rudski and Prognosis of Patients Patients of Prognosis and Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS al. et JU, Doherty SR, Bailey MJ, Wolk Multimodality Imaging in Valvular Imaging Multimodality for Criteria Use Appropriate 2017 ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS P. Soman P, Schoenhagen R, S, Mehran Kort JU, Doherty doi:10.1161/cir.0000000000000029. Circulation Summary. Executive Disease: Heart Valvular With Patients of Management the for Guideline AHA/ACC 2014 al. et RO, Bonow CM, Otto RA, Nishimura doi:10.1023/a:1011973530231. - 2001;17(5):339 . Imaging Cardiac of Journal International The block. branch bundle left with in patients disease artery coronary of diagnosis for echocardiography stress thallium of Comparison al. A,et Yanik E, Yetkin I, Tandoğan Echocardiography of Society American of the Journal Echocardiography. Stress of Application and Interpretation, Performance, for Recommendations Pel – 2005;46:1606 Cardiol Coll Am J imaging. cardiovascular of appropriateness the evaluating for method proposed ACCF IE. Raskin JM, Allen MJ, ED, Wolk Peterson PS, Douglas RC, Hendel RG, Brindis JA, Spertus MR, Patel ACCF: by outlined methodology and principles the with accordance in EchocardiographyDeveloped Stress for Criteria Appropriateness 2008 ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR NJ. RF, Weissman Stainback B, Khandheria PS, Douglas - 2007;100(3):536 American College of Cardiology of College American the of Journal Echocardiography. Exercise and Imaging Perfusion Myocardial Exercise Normal of Value Prognostic KE. The Fleischmann D, Grady RF, Redberg R, Hom M, Beattie LD, Metz S, Yao S Bangalore Cardiology Committee for Practice Guidelines. Guidelines. Practice for Committee Cardiology of Society European andthe Documents Consensus Expert onClinical Force Task Foundation Cardiology of College American the of A report Cardiomyopathy onHypertrophic Document doi:10.1016/j.jacc.2007.12.005. - 2017;70(13):1647 doi:10.1016/j.echo.2007.07.003. - doi:10.1016/s0195 Thoracic Surgeons. Circulation. 2008;118(23). doi:10.1161/circulationaha.108.190690. 2008;118(23). Circulation. Surgeons. Thoracic of Society and Interventions, and Angiography Cardiovascular for Society Disease, Heart Congenital Adult for Society International Society, Rhythm Heart Echocardiography, of Society American the With in Collaboration Developed Disease): Heart Congenital With Adults of Management the on Guidelines Develop to Committee (Writing Guidelines Practice on Force Task Association Heart Cardiology of College American the of A Report Disease: Heart Congenital Adults With of Management the for Guidelines 2008 ACC/AHA al. et TM, RG, Bashore CA, Williams Warnes Holmes DR, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Document Consensus Expert ACCF/AATS/SCAI/STS 2012 al. et S, Kaul MJ, Mack DR, Holmes Maron B. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Expert Clinical Cardiology of Society Cardiology/European of College American B. Maron

likka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography of Society American SG. Sawada CA, Kuehl AA, Elhendy SF, PA, Nagueh likka eviCore healthcare eviCore

GuidelinesImaging 543. doi:10.1016/j.amjcard.2007.03.057. 543. - 2009;22(9):975 . 1672. doi:10.1016/j.jacc.2017.07.732. 1672. - 668x(03)00479 - S, Chaudhry FA. Usefulness of Stress Echocardiography for Risk Stratification Risk for Echocardiography Stress of Usefulness FA. Chaudhry S, . All All . 13. 13.

w Jo Rights Reserved. Rights rdiology Ca of Journal American The Hypertrophy. Ventricular Left ith - 2010;23(7):685 . urnal of the American College of Cardiology of College American the of urnal - 2007;49(2):227 .

Journal of the American College of Cardiology of College American the of Journal Disease. Heart 2. 09.07.013. doi:10.1016/j.echo.20 1014.

713. doi:10.1016/j.echo.2010.05.010. 713. European Heart Journal Heart European 237. doi:10.1016/j.jacc.2006.08.048. 237. - 2007;20(9):1021 . 8924 - 201 exercise SPECT and dobutamine and SPECT 201 exercise - 2014;129(23):2440 . 345. - 2003;24(21):1965 . - 2014;63(4):380 . 1041. - 2008;51(11):1127 . - 2012;93(4):1340 . 2492. www.eviCore.com /American Page 406. 1991. 1395. 1147. 25 V1.0 . of . 92

Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______14. Cardiac 15. 17. 16. © 2019 - 2013;65(12):3194 Rheumatism. Disease Tissue Connective of Detection and Screening for Recommendations al. et R, Channick H, Gladue D, Khanna doi:10.1016/j.jacc.2013.10.029. Cardiology of College American the of Journal Hypertension. Pulmonary of Classification Clinical Updated al. et I, Adatia MA, Gatzoulis G, Simonneau Echocardi of Society American the of Journal Echocardiography. Transesophageal with Guidance Image Procedural Occlusion/Exclusion: Appendage Atrial al. et Left W, Jaber SC, Harb AF, Vainrib - 2008;118(21):2183 Circulation. Hypertension. Arterial - Exercise DM. Systrom PP, Pappagianopoulos TLV, AB, Horn JJ, Waxman Tolle

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GuidelinesImaging - 2018;31(4):454 ography. . All All .

Rights Reserved. Rights - Associated Pulmonary Arterial Hypertension. Arthritis & Arthritis Hypertension. Arterial Pulmonary Associated 3201. doi:10.1002/art.38172. 3201. 474. doi:10.1016/j.echo.2017.09.014. 474.

. doi:10.1161/circulationaha.108.787101 2189. 8924 . 2013;62(25). . Induced Pulmonary Induced www.eviCore.com Page 26 V1.0 of 92

Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD-3: Nuclear Cardiac Imaging CD-3.1: Myocardial Perfusion Imaging (MPI) – Coding 28 CD-3.2: MPI – Indications 28 CD-3.3: MUGA – Coding 29 CD-3.4: MUGA Study – Cardiac Indications 30 CD-3.5: MUGA Study – Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD) 31 CD-3.6: Myocardial Sympathetic Innervation Imaging in Heart Failure 31 CD-3.7: Myocardial Tc-99m Pyrophosphate Imaging 31 CD-3.8: Cardiac Amyloidosis 32

______©2019 eviCore healthcare. All Rights Reserved. Page 27 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ MPI –CD-3.2:     – (MPI) Imaging Perfusion Myocardial CD-3.1: Cardiac © (exercise or(exercise pharmacologic) and/or redistribution rest and/or reinjection additional quantification, when at studies, multiple and/or performed); rest stress quan MPI, tomographic attenuation (including or(SPECT) correction, qualitative pharmacologic) or additional single quantification, when at reststudy, performed); or stress (exercise quantitative MPI, tomographic attenuation (including or(SPECT) correction, qualitative Perfusion Myocardial Imaging (MPI) 2019 See: services are reimbursed according to each individual payer policy. 93018) and radiopharmaceuticals should be assigned in addition to MPI. These Separate codes suchfor related services as treadmill testing (CPT MPI. 3D rendering, (CPT procedure on the date all portions of the study are completed. performed on separate calendar dates. A single code is assigned to define the entire not appropriate to billseparately thefor Multi    CPTstress, commonlyThe most

titative wall motion, ejection fraction by first pass or gated technique, technique, orpass gated by first fraction ejection wallmotion, titative eviCore healthcare eviCore

conjunction with MPI codes. CPT correction. definition. No additional code should be assigned for the billing of attenuation Attenuation correction, when performed, is included in the MPI service by code (CPT studies, First pass routinely performed during Evaluation of the individual’s left ventricular wall motion and ejection fraction are GuidelinesImaging

- CD- day Studies: ® wall motion, ejection fraction by first pass or gated technique, technique, orpass gated by first fraction ejection wallmotion, 1.4: Stress Testing with 78473) and SPECT MUGA (CPT ® 78451) and multiple (at rest and stress, CPT

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performed myocardial perfusion imaging are single (at rest or 76376/CPT Rights Reserved. Rights ® 78481 andCPT

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Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD -3.4: MUGA Study – Cardiac Indications

MUGA (Multi Gated Acquisition) – Blood Pool Imaging Indications  Echocardiography is the preferred method of following left ventricular systolic function. Indications below refer to scenarios in which MUGA may be performed rather than ECHO:  Prior ECHO demonstrates impaired systolic function (EF < 50%).  Pre-existing left ventricular wall motion abnormalities from ischemic heart disease or ischemic or non-ischemic cardiomyopathies.  ECHO is technically limited and prevents accurate assessment of LV function.  AICD placement:  MUGA to assess LV ejection fraction when there are conflicting results between other forms of testing and the issue is clinically relevant, e.g., MPI LVEF is 80% and an echo EF is 30%, the MUGA would be appropriate.  However, if the MPI LVEF is 80% and the echo EF is 50%, this would not be appropriate even though the difference is significant since the echo EF is still normal.  Congestive heart failure:  MUGA to measure response to cardiac medications for CHF if echocardiogram was performed and was technically difficult  Previous low LV ejection fraction determination was < 50% and receiving potentially cardiotoxic chemotherapy  Documentation of other need for information given by MUGA that cannot be obtained by ECHO  First pass studies (CPT® 78481 and CPT® 78483) may be approved when indications are met for MUGA and/or there is need for information that cannot be obtained by MUGA

MUGA is NOT indicated for the following:  A prior MUGA is not a reason to approve another MUGA (it is not necessary to compare LVEF by the same modality)  To resolve differences in ejection fraction measurements between ECHO and MPI unless there is clear documentation as to how quantitative measurement of LVEF will affect patient management (e.g. implantation of an AICD).

Practice Notes:  LV ejection fraction measurement is variable and can vary by +/-5-10% without any accompanying change in clinical status. Normal physiologic changes in intravascular volume, catecholamine levels, fever, and medications are among the many factors which cause variation in LVEF in the absence of myocardial pathology.  Right ventricular first pass study, (CPT® +78496), may be indicated if there is clear documentation of a concern regarding right ventricular dysfunction or overload. Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 30 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Tc Myocardial CD-3.7:    in H Imaging Innervation Sympathetic Myocardial CD-3.6:  Therapeutics – Study MUGA CD-3.5: Cardiac © : Note (SPECT). tomographic agent(s) radiopharmaceutical P area limited agent(s); radiopharmaceutical of distribution or tumor of localization A SPEC tomographic quantitative or qualitative planar, avid, infarct Imaging, Myocardial technique pass first by fraction ejection with quantitative or qualitative planar, avid, infarct Imaging, Myocardial avi infarct Imaging, Myocardial MUGA (Mu with the SPECT included be should areas multiple or area a limited of imaging planar 78803, 2019 lanar with SPECT, Radiopharmaceutical loca Radiopharmaceutical SPECT, with lanar single planar imaging session alone (without a SPECT study),Radiopharmaceutical study),Radiopharmaceutical SPECT a (without alone session imaging planar single use for this indication is limited. See CD-5 and specificity for identifying infarcted myocardial tissue are infarction, hence, the term "infarct Historically this method of imaging the myocardium was used to identify recent   studies: The AMA has established the following set of Category III codes to report these investigational purpose. eviCore currently considers AdreView to beexperimental and iodobenzylguanidine), is the only FDA increased myocardial sympathetic activity. Currently, AdreView Markers have been developed, using radioactive iodine, i this compensatory mechanism is detrimental and causes further damage. thefordecreased myocardial function. In heart failure, the sympathetic nervous system is activated in order to compensate ( Dysfunction See

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99m pyrophosphate imaging may beindicated to identify cardiac amyloidosis 99m pyrophosphate such as renal insufficiency or animplantable cardiac device. Patients with suspected cardiac ATTR amyloidosis and contraindications to CMR withconsistent ca Diagnosis of cardiac ATTR in individuals with CMR or echocardiography amyloidosis. Evaluation of cardiac involvement in individuals with known or suspected familial and signs/symptoms of heart failure. carpal tunnel syndrome or atrial arrhythmias in Individuals, especially elderly males, with unexplained neuropathy, bilateral ejection fraction. Individuals over the age of 60 years with unexplained heart failure andpreserved with increased left ventricular wall thickness (> 12mm). African thickness. Individuals with heart failure and unexplained increase in left ventricular wall GuidelinesImaging Cardiac Amyloidosis Cardiac - Americans over the age of 60 years with heart failure, unexplained or

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Cardiac Imaging 8. 4. 16. 14. 13. 12. 11. 10. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______15. 9. 7. 6. 5. 3. 2. 1. References Cardiac © 2019 Highlights Of Prescribing Information HERCEPTIN Information Prescribing Of Highlights Medicine iovascular Card in Reviews Cardiotoxicity. and Chemotherapy NE. Lepor RA, Gottlieb H, Broder . doi.org/10.1016/j.amjcard.2009.02.059 %20Resources/Practice%20Points/ASNC%20Practice%20Point https://www.asnc.org/Files/Practice Amyloidosis. Cardiac Imaging Cardiovasc Circ amyloidosis cardiac diagnosing - http://www.gene.com/gene/products/information/pdf/herceptin 2017. April Revised: 1998. Approval: U.S. Initial Medicine of Journal Clinic Cleveland angina? classic with apatient for test best the is MS. What Lauer Cardiology of College American the of Journal Imaging. Radionuclide Cardiac for Criteria Use Appropriate ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/ al. MFD, et DS, Carli Berman Hendel RC, - 24:4107 2006 Sept; Oncology Clinical J experience. Center Cancer Anderson M.D. the cancer: breast - Long al. V, et Valero DJ, Lenihan V, Guarneri Cardiol Am J et CJ, Pepine SB, King VE, Friedewald trial). COURAGE the (from disease artery coronary - long on intervention coronary percutaneous without or with therapy medical optimal of Impact al. et KK, Teo RA, O’Rourke Boden WE, doi:10.1056/nejmoa070829 - 2007;356(15):1503 . Medicine of Journal England New Disease. Coronary Medic Optimal al. et KK, Teo RA, O'rourke Boden WE, https://www.aapm.org/pubs/reports/RPT_96.pdf and reporting measurement, “The 23, Group Task AAPM of Report 2008. January 96, Report (AAPM) Medicine in Physicists of Association American - 2011;4(6):659 - Transthyretin Hereditary of Prognosis Tomography (SPECT) Myocardial Perfusion Imaging Guidelines: Instrumentation, Acquisition, Instrumentation, Guidelines: Imaging Perfusion Myocardial (SPECT) Tomography Emission Photon Single al. et IS, K, Armstrong S, Ananthasubramaniam Dorbala Dorbala S, Bokhari S, Miller E, et al. 99mTechnetium al. E, et Miller S, S, Bokhari Dorbala Imaging Imaging. Cardiovascular of Association European and the Echocardiography of Society American the from areport therapy: cancer after and during patients adult of evaluation imaging multimodality for consensus Expert al. A, et Barac M, Galderisi JC, Plana 0202- light al. et (99m)Tc T, Pozniakoff A, Castano S, Bokhari technetium of Sensitivity al. A, et Rubinow VW, Lee RH, Falk Iodine imaging: innervation sympathetic Myocardial Policy: Coverage Model ASNC/SNMMI al. et AE, Buxton M, Gerson 99mTechnetiumPyrophosphateImaging2016.pdf Rapezzi C, Quarta CC, Guidalotti PL, et al. Role of 99mTc of Role al. et PL, Guidalotti CC, Quarta C, Rapezzi Processing, and Interpretation. and Processing,

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- GuidelinesImaging - transthyretin the from amyloidosis cardiac chain 8. . 2014;15(10):1063 . 4115

- 9(2):75 2008; ; 74 Feb 2007 - 2009;53(23):2201 . ,

. - 100(11):1635 Dec; 2007 . doi:10.1016/j.jcmg.2011.03.016 670. doi: . 10.1200/JCO.2005.04.9551 ASNC PRACTICE POINTS 2016. POINTS PRACTICE ASNC . All All . - (2):123

83. 83. . d 6:195 2013; Rights Reserved. Rights - . . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723407 - 1093. doi:10.1093/ehjci/jeu192 1093. 123 m . doi:10.1016/j.jacc.2009.02.013 2229.

. 126 . - doi:10.1007/s12350 2018. Cardiology. Nuclear of Journal . . 51:826 1983; Cardiol J Am - eta

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term cardiovascular end points end cardiovascular term . doi:10.1016/j.amjcard.2007.09.001 term cardiac tolerability of trastuzumab in metastatic trastuzumab of tolerability cardiac term . . management of radiation dose in CT.” dose radiation of management ® - pyrophosphate scintigraphy for differentiating for scintigraphy pyrophosphate

Am J Cardiol, J Am (trastuzumab) for injection, for intravenous use intravenous for injection, for (trastuzumab) related familial and senile cardiac senile and familial related - Imaging for Transthyretin for Imaging Pyrophosphate al Therapy with or without PCI for PCI Stable for without or with al Therapy - - - Journal Heart European . DPD Scintigraphy in Diagnosis and Diagnosis in Scintigraphy DPD 8924 - doi:10.1016/S0002 - - 123- 99m pyrophosphate scintigraphy in scintigraphy pyrophosphate 99m prescribing.pdf

is. is. 2009 July 2009 mIBG). d mIBG). . Imaging Cardiovascular JACC: 1516.

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Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD-4: Cardiac CT, Coronary CTA, and CT for Coronary Calcium (CAC) CD-4.1: Cardiac CT and CTA – General Information and Coding 35 CD-4.2: CT for Coronary Calcium Scoring (CPT® 75571) 36 CD-4.3: CCTA – Indications for CCTA 36 CD-4.4: CCTA – Additional Indications 37 CD-4.5: Fractional Flow Reserve by Computed Tomography 38 CD-4.6: CT Heart – Indications 38 CD-4.7: CT Heart for Congenital Heart Disease 38 CD-4.8: Transcatheter Aortic Valve Replacement (TAVR) 39

______©2019 eviCore healthcare. All Rights Reserved. Page 34 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ CTA– CTand Cardiac CD-4.1: Cardiac ©   model tomodel reconcile data, discordant interpretation artery disease; data coronary anatomical review with in comparison estimated FFR software analysisphysiologic simulation of assessfunctional data to the severity of tomographycomputed data using angiography computation dynamics fluid Noninvasive esti andhyperemia, of estimated FFR generation model artery disease; coronary analysis dynamicsfluid andsimulated of maximal coronary software analysisphysiologic simulation of assessfunctional data to the severity of tomographycomputed data using angiography dynamicscomputation fluid coronary Noninvasive reserveflow (FFR)fractional derived estimated coronary from artery disease; coronary preparation and data transmission software analysisphysiologic simulation of assessfunctional data to the severity of tomographycomputed data using angiography computation dynamics fluid coronary Noninvasive reserveflow (FFR)fractional derived estimated coronary from data, discordant interpretation reconcile and report with anatomicalmodel, data review inwith FFR comparison estimated model to dynamics andsimulated hyperemia,maximal coronary ofgeneration estimated FFR artery disease; coronary preparation and data analysis transmission, of fluid software analysisphysiologic simulation of assessfunctional data to the severity of tomographycomputed data using angiography computation dynamics fluid coronary Noninvasive reserveflow (FFR)fractional derived estimated coronary from of assessment andcardiac function, evaluat 3D imageincluding post heart,CTA, coronary arteries andbypass grafts (when with contrast, present), cardiac functio of of heartsetting congenital disease heart, withCT, contrast, evaluation cardiacfor and of structure morphology venous structures,of performed). if 3D image post (including heart, withCT, contrast, evaluation cardiacfor and of structure morphology r CPT assessmentfunctional (for example, calcium scoring set code The Cardiac CT andCCTAfor ( heart, withoutCT, contrast, with quantitative of evaluation coronary c 2019 eported onlyeported scoring when is performed calcium a standas - coronary artery disease has been confirmed in high The CPT ofamount calcium such that original the Can beused to report a non- preliminary (CPT ®

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man age Mustbe aman Mustbe amember of afully Mustbe aTexasresident. study within the past 5 years. Must not have had a calcium scoring study or acarotid intima- higher. Must have either diabetes or a Framingham cardiac risk score of intermediat GuidelinesImaging ® 75574 includes evaluation of cardiac structure and C (CPT Scoring Calcium Coronary CT for Heart Attack Preventive Screening Law (HR 1290) mandates that insurers in see .

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cardiomyopathy. been performed since the diagnosis of congestive heart failure or No cardiac catheterization, SPECT, cardiac PET, or stress echocardiogram has No exclusions to cardiac CT angiography. percent, and low or intermediate risk onthe pre- No prior history of coronary artery disease, the ejection fraction is less than 50 artery or bypass graft location. anomalous coronary artery in relation to the great vessels Prior nondiagnostic coronary angiography in determining the course of the angiography Resuscitated sudden death and contraindications for conventional coronary documented with history sibling(s) Full Persistent exertional chest pain and normal stress test,  Report CPT Rep that alternative ways to enter the chest can be planned. To identify whether bypass grafts are located directly beneath the sternum, so GuidelinesImaging do CABGdo

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Cardiac Imaging 13. 12. 11. 10. 9. 8. 14. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______7. 6. 5. 4. 3. 2. 1. References Cardiac © 2019 doi:10.1161/cir.0b013e3181fcae66. 2010;122(21). . Circulation Tomography. Computed Cardiac for Criteria Use Appropriate 2010 ACCF/SCCT/ACR/AHA/ASE/ASNC/NAS al. et JM, Hodgson M, Cerqueira AJ, Taylor doi: 2017. 1, November ; 68:4352016 Cardiology, of - doi:10.3978/j.issn.2223 16- using grafts bypass artery coronary of visualization Noninvasive al. P, et Hunold T, Konorza T, Schlosser doi:10.1001/jama.298.3.317. . https://doi.org/10.1161/CIRCULATIONAHA.106.178458 59:1200. 2012; Cardiology, of College American the of Journal replacement. valve aortic transcatheter on document consensus expert ACCF/AATS/SCAI/STS 2012 al. S, et Kaul M, Mack Jr, D Holmes . syndrome coronary acute to atherosclerosis CT: Cardiac al. et DTL, RK, Wong Munnur JD, Cameron BS, Ko Cardiology of College American the of Journal disease artery coronary suspected in angiography tomography computed coronary from derived reserve flow fractional noninvasive of performance Diagnostic al. S, et Gaur J, Leipsic B, Norgaard The disease: coronary suspected with patients 1- al. et MR, Patel G, Pontone B, DeBruyne PS, Douglas Exposure From 64- From Exposure Radiation With Associated Cancer of Risk Estimating S. Rajagopalan MJ, Henzlova AJ, Einstein . Cardiology Clinical on Council Imaging, onCardiac Committee and Intervention, and Radiology Cardiovascular on Council Intervention, and Imaging Cardiovascular on Committee Association Heart American the From Statement Scientific tomography: computed cardiac by disease artery coronary of Assessment al. et RS, Blumenthal S, Achenbach MJ, Budoff . doi:10.1016/j.amjcard.2006.02.046 arteries. coronary anomalous of diagnosis the for angiography coronary tomographic computed multislice of Use al. et KB, Johnson WD, Dockery RF, Berbarie with cardiomyopathy. dilated in patients angiography coronary tomography computed multidetector of accuracy Diagnostic al. et M, Pepi G, Pontone D, Andreini . doi:10.1016/j.jacc.2006.10.001 Cardiol Am Coll J Tomography. Computed Cardiovascular of Society the and Prevention and Imaging Atherosclerosis of Society the with in collaboration developed Tomography) Computed Beam Electron on Document Consensus Expert 2000 the Update to Committee Writing (ACCF/AHA Force Task Consensus Expert Clinical Foundation Cardiology of College American the of a report pain: chest with patients of in evaluation and assessment risk cardiovascular global in tomography computed by scoring calcium artery on coronary document consensus expert clinical 2007 ACCF/AHA al. et BH, Brundage RO, Bonow P, Greenland CollCardiol Nuclear of Society American the Echocardiography, of College American the Tomography, Computed Cardiovascular of Society the Force, Task Criteria Use Appropriate Foundation Cardiology of College American the of a report tomography: computed cardiac for criteria use appropriate 2010 NASCI/SCAI/SCMR ACCF/SCCT/ACR/AHA/ASE/ASNC/ al. et JM, Hodgson M, Cerqueira AJ, Taylor - 48(7):1475 ; CollCardiol2006 imaging resonance magnetic cardiac and tomography computed for Criteria Appropriateness RC, Hendel . doi:10.1016/j.jacc.2007.01.086 2050. . Published February 2017. February Published . https://www.nice.org.uk/guidance/mtg32 excellence. care and health for Institute National NICE: Guidance. angiography: CT coronary from reserve flow fractional estimating for FFRCT HeartFlow Overview: committee. advisory technology medical NICE Angio Cardiovascular for Society the Imaging, Cardiovascular for Society American North the Cardiology,

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______15. Cardiac 16. 17. 18. © 2019 Medicare Learning Network Learning Medicare QuickReferenceChart https://www.cms.gov/Medic . doi:10.1161/CIR.0b013e3181d4b618 55:2663. 2010; Cardiology of College American the of Journal Documents. Consensus onExpert Force Task Foundation Cardiology of College American the of a report angiography: tomographic computed coronary on document consensus expert 2010 ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT al. et DS, Berman DB, Mark Documents, Consensus Expert on Force Task Foundation Cardiology of College American - doi:10.1007/s12350 2063. - 2017;24(6):2043 Cardiology. Nuclear of Journal Disease. Heart Valvular in ging Ima Multimodality for Criteria Use Appropriate 2017 ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS P. Soman P, Schoenhagen R, S, Mehran Kort JU, Doherty criteria for multimodality imaging in valvular heart disease (2017) disease heart valvular in imaging multimodality for criteria use Appropriate (STS): Surgeons Thoracic of (SCMR)/Society Resonance Magnetic Cardiovascular for (SCCT)/Society Tomography Computed Cardiovascular of (SCAI)/Society Interventions and Angiography Cardiovascular for Society (HRS)/Society Rhythm (ASNC)/Heart Cardiology Nuclear of Society American (ASE)/ Echocardiography of Society (AHA)/American Association Heart (AATS)American Surgery Thoracic for Association (ACC)/American Cardiology of College American The Medicare Learning Network Learning Medicare The

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Cardiac Imaging 9. 8. 3. 2. 7. 10. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______11. 6. 5. 4. 1. References Cardiac © 2019 Woodard PK, Bluemke DA, Cascade PN, et al. ACR al. et PN, Cascade DA, Bluemke PK, Woodard Circulation Society. Autonomic American by the endorsed Society: Rhythm Heart the with collaboration in Foundation: Cardiology of College American the and Group; Working Interdisciplinary Research Outcomes and Care of Quality andthe Stroke, and Young, the in Disease Cardiovascular Nursing, Cardiovascular Cardiology, onClinical Councils Association Heart American the from syncope: Biaggiono DW, Benson SA, Strickberger fibrillation. atrial of ablation catheter radiofrequency before morphology vein pulmonary of characterization for tomography computed versus imaging resonance Magnetic al. et R, K, Roettgen A, Charalampos Hamdan d study. electrophysiologic and negative Circulation experience. States a United dysplasia: ventricular right Arrhythmogenic al. et C, Bomma K, Nasir D, Dalal - Long al. et G, A, Gasparini Proclemer A, Raviele . doi:10.1161/CIRCULATIONAHA.109.852517 https://doi.org/10.1016/j.jacr.2006.06.007 - 2006:665 CollRadiol Am J (MRI). imaging resonance magnetic cardiac of interpretation . doi:10.1016/j.jacr.2006.06.007 - :665 2006 CollRadiol Am J (MRI). imaging resonance magnetic cardiac of interpretation - 121:674 2008; , Medicine of Journal American The update. A clinician’s cardiomyopathies: defined Recently al. et F, Marcus VL, Sorrell R, Ramaraj Med J Am review. literature Kap - 48(7):1475 ,2006; CollCardiol Am J imaging. resonance magnetic cardiac and tomography computed for Criteria Appropriateness 2006 ASNC/NASCI/SCAI/SIR ACCF/ACR/SCCT/SCMR/ et al. MR, Patel CM, Kramer RC, Hendel imaging. resonance magnetic - delayed of significance Prognostic al. et JM, R, Wilson Muthupillai BYC, Cheong Woodard PK, Bluemke DA, Cascade PN, et al. ACR al. et PN, Cascade DA, Bluemke PK, Woodard Surgeons. Circulation Surgeons. and Interventions, and Angiography Cardiovascular for Society Disease, Heart Congenital Adult for Society International Society, Rhythm Heart Echocardiography, of Society American the With Collaboration in Developed disease). heart congenital with adults of management the on guidelines develop to committee (writing Guidelines onPractice Force Task Association Heart Cardiology/American of College American the of a report Disease: Heart Congenital with Adults of Management the for Guidelines 2008 ACC/AHA al. et TM, RG, Bashore CA, Williams Warnes oi:

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oor WN, Smith MA, Miller NL. Upright tilt testing in evaluating syncope: acomprehensive syncope: evaluating in testing tilt Upright NL. Miller MA, Smith oor WN, GuidelinesImaging

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Cardiac Imaging 2. 5. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______6. 1. References   Cardiac 4. 3. © 2019 Cardiac Sarcoidosis. Journal of Nuclear Medicin Nuclear of Journal Sarcoidosis. Cardiac 18F Fasting of Usefulness al. et T, Toyama T, Iwasaki W, Okumura . Published February Published . http://jnm.snmjournals.org/content/53/2/241.long Medicine. Nuclear of Journal Experience. Ontario the Including Metaanalysis and Review A Systematic Sarcoidosis: 18F of Use The al. et E, Leung I, Mylonas G, Youssef - 2014;63(4):329 Cardiology. of College American the of Journal Sarcoidosis. Cardiac Suspected With Patients of Assessments Prognostic Enhances Tomography Emission Positron Cardiac al. et M, Naya M, Osborne R, Blankstein - 2007;116(11):1290 Circulation. Imaging. Diagnostic Cardiac from Patients to Dose Radiation al. et RC, Thompson KW, Moser AJ, Einstein - 2006;48(5):1029 Cardiology. Rubidium Using Imaging Perfusion Myocardial of Value Prognostic the is al. K, et What BJ, Williams K, Chow Yoshinaga 20 1, January Published Medicine. Nuclear of Journal Antibodies. Monoclonal Radiolabeled with Therapy on Cancer Perspectives DM. Goldenberg RM, Sharkey 2004. 1, December Published examination, This study may beperformed in conjunction with aCardiac PET perfusion cardiac sarcoid. To identify and monitor response to therapy for established or strongly suspected

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Cardiac © 2019      maybe needed LHC is indicated for any   SymptomaticpatientswithahighpretestprobabilityofCAD:   s

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 Evaluation pri        following conditions: the clinical problem, or led to aconclusion that intervention is indicated for the Recent noninvasive cardiac testing was equivocal, unsuccessful in delineating Unheralded syncope (not near syncope) unclear. Ventricular fibrillationor having coronary arterydisease. Left ventricular dysfunction (congestive heart failure) in patients suspected of   Persistent or worsening symptoms to evaluate progression of known CAD when:   such as: of breath, etc.) with evidence of significant ischemia on recent stress testing, syndrome (ACS) occurring at rest A recent history of unstable angina-   GuidelinesImaging Symptoms concerningfororonaryarteryischemia(chestdiscomfort,shortnes

ee CD-1 k organ aneurysm, congenital disease repair such as atrial septal defect, etc.).Pre- great vessel surgery(i.e. cardiac valve surgery, aortic dissection, aortic Ruling out coronary artery disease prior to planned non- Evaluation of structural disease Evaluation of previously placed coronary artery stents Evaluation of coronary grafts An intermediate or large amount of myocardium (>5%) may be in jeopardy Significant/serious ventricular arrhythmia Suspicion of endocarditis, or my C provide pain relief. General Issues – Angina that is unresponsive to optimized medical therapy see indicated delineating the clinical problem, or led to a conclusion that intervention is Recent noninvasive cardiac testing was equivocal, unsuccessful in At least moderate size area of hypokinesis on stress echo test At least moderate ischemia (medium to large size defect) on imaging stress new onset, accelerating, or worsening symptoms consistent with patient’s suggestive unstable of angina new nown anginapatterninanindividualwithahistoryofCABGorPCI ardiomyopathy

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ CD-     CD- : CD-7.4 Cardiac © 2019                 management of any Diagnostic Right heart cath is indicated when results will impact the diagnosis and Cardiac outputs are calculated by several techniques including thermodilution. ventricular pressures. Pressure measurements are made and are done simultaneously with aortic and left It includes a full oximetry detection for and quantification of shunts. subclavian or internal jugular veins andinter It is performed most commonly from the femoral vein, less often through the    – – Catheterization Heart Right Diagnostic 7.4.2: .1 7.4

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  Assessment Uncertain intravascular volume status with an unclear etiology Pre During aleft heart cath where the etiology of the symptoms remains unclear. Newly diagnosed or worsening cardiomyopathy Preoperative evaluation Left heart failure Rightheart failure Valvular disease Pericardial diseases (constrictive or restrictive pericarditis) Pulmonary hypertension Congenital defects including persistent left vena cava Anomalous pulmonary venous return Patent foramen ovale(PFO) Ventricular septal defect (VSD) including shunt detection and quantification Atrial septal defect (ASD) including shunt detection and quantification  Previous Suspectedpericardial disease.   Valvularheart disease when  GuidelinesImaging

Right Heart Catheterization (RHC) Catheterization Heart Right evaluation. Either is appropriate and can be approved but NOT of their initial evaluation protocol. Others use an imaging stress test for Assess for rejection for Assess For routine endomyocardial biopsy P Valvular and non- the To a To transplantation. - : lung transplant to assess pulmonary pressures er transplant center protocol General information RHC information General re is a discrepancy between the clinical findings (history, physical exam, ssess for accele for ssess

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Cardiac Imaging Cardiac Imaging Guidelines V1.0

 Assess pulmonary artery pressure  Can be done per the institution protocol or anytime organ rejection is suspected and biopsy is needed for assessment  Evaluation of right ventricular morphology.  Suspected arrhythmogenic right ventricular dysplasia.

CD-7.5: Combined Right and Left Heart Catheterization Indications  Preoperative evaluation for valve surgery  The indications for CD-7.3: Diagnostic Left Heart Catheterization are met and any of the following are present:  The major component of the patient symptoms is dyspnea  The indications are met according to CD-7.4: Right Heart Catheterization  Newly diagnosed or worsening cardiomyopathy

CD-7.6: Planned (Staged) Coronary Interventions  The CPT® codes for percutaneous coronary interventions (PCI) include the following imaging services necessary for the procedure(s):  Contrast injection, angiography, ‘road-mapping’, and fluoroscopic guidance  Vessel measurement  Angiography following coronary angioplasty, stent placement, and atherectomy  Separate codes for these services should not be assigned in addition to the PCI code/s because the services are already included.  A repeat diagnostic left heart catheterization is not medically necessary when the patient is undergoing a planned staged percutaneous coronary intervention.

Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 55 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 7. 6. 5. 4. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______3. Friedewal 2. 1. References Cardiac © 2019 - 2014;130(19):1749 Circulation. Surgeons. Thoracic of Society and Interventions, and Angiography Cardiovascular for Society Association, Nurses Cardiovascular Preventive Surgery, Thoracic for Association American the and Guidelines, Practice Force Task Association Heart Cardiology/American of College American the of A Report Disease: Heart Ischemic Stable Patients With of Management and Diagnosis the for Guideline the of Update Blankenshi SD, Fihn doi:10.1016/j.jacc.2012.07.013 2012;60(24). Cardiology. of College American the of Journal Disease. Heart Ischemic Stable With Patients of Management and Diagnosis Fihn SD, Gardin JM, Gardin SD, Fihn Undergoing Noncardiac Surgery. Circulation. 2016;134(10). doi:10.1161/cir.0000000000000404. 2016;134(10). Circulation. Surgery. Noncardiac Undergoing Patients of Management and Evaluation Cardiovascular on Perioperative Guideline ACC/AHA 2014 – Non With Patients of Management the for Guideline ACCF/AHA Guideline for the Management of ST of Management the for Guideline ACCF/AHA 2013 Disease, Heart Ischemic Stable With Patients of Management and Diagnosis the for Guideline ACC 2012 Surgery, Graft Bypass Artery Coronary for Guideline ACCF/AHA 2011 Intervention, Coronary Percutaneous for Guideline ACCF/AHA/SCAI 2011 the of An Update Guidelines: Practice onClinical Force Task Association Heart Cardiology/American Americ the of A Report Disease: Artery Coronary in Patients With Therapy Antiplatelet Dual of Duration on Update Focused Guideline ACC/AHA 2016 al. et JA, Bittl ER, Bates GN, Levine - 2014;130(25):2354 Circulation. s. Guideline onPractice Force Task Association Heart Cardiology/American of College American - Non With Patients W EA, Amsterdam TheHeart.org. TheHeart.org. Contraindications. Indications, Background, Heart: Left of Catheterization Cardiac RB. Olade . doi:10.1016/j.amjcard.2007.09.001 - 2007;100(11):1635 Cardiology. of Journal American The Pectoris. Angina Stable doi:10.1056/nejmoa070829 - 2007;356(15):1503 Medicine. of Journal England New Disease. Coronary O' WE, Boden 2017. Accessed September 19, 2018. 19, September Accessed 2017.

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GuidelinesImaging d VE, King SB, Pepine CJ, Vetrovec GW, Roberts WC. The Editor’s Roundtable: Chronic Roundtable: Editor’s The Roberts WC. GW, Vetrovec CJ, Pepine SB, King d VE, R - https://emedicine.medscape.com/article/1819224 ourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable for PCI without or with Therapy Medical Optimal al. et KK, Teo RA, ourke enger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Management the for Guideline AHA/ACC 2014 al. et RG, Brindis NK, enger ST p JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused ACC/AHA/AATS/PCNA/SCAI/STS 2014 al. et KP, Alexander JC, p

Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the for Guideline ACCF/AHA/ACP/AATS/PCNA/SCAI/STS 2012 al. et J, Abrams - . All All . Elevation Acute Coronary Syndromes: Executive Summary: A Report of the of A Report Summary: Executive Syndromes: Coronary Acute Elevation

Rights Reserved. Rights . . doi:10.1161/cir.0000000000000133 2394. .

- Elevation Myocardial Infarction, 2014 AHA/ACC 2014 Infarction, Myocardial Elevation 0.1161/cir.0000000000000095 doi:1 1767. ST - Elevation Acute Coronary Syndromes, and Syndromes, Coronary Acute Elevation 8924 /AHA/ACP/AATS/PCNA/SCAI/STS overview . Published January 7, January Published . 1516. 1643. www.eviCore.com an College of an College Page 56of92 . V1.0 on

Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD-8: Pulmonary Artery and Vein Imaging CD-8.1: Pulmonary Artery Hypertension (PAH) – Indications 58 CD-8.2: Pulmonary Vein Imaging – Indications 58

CD-8.1: Pulmonary Artery Hypertension (PAH) – Indications  CT or CTA or MRA of the pulmonary arteries (CPT® 71260 or CPT® 71275 or CPT® 71555) is useful in the assessment of PAH, especially if there is suspicion for recurrent pulmonary emboli.  In the absence of a clinical change, follow-up imaging for PAH is not indicated.  Also see:  PVD-5: Pulmonary Artery Hypertension in the Peripheral Vascular Disease Imaging Guidelines.  CH-25: Pulmonary Embolism (PE) in the Chest Imaging Guidelines.

CD-8.2: Pulmonary Vein Imaging – Indications  Cardiac MRI (CPT® 75557 or CPT® 75561 ), Chest MRV (CPT® 71555), Chest CTV (CPT® 71275), or Cardiac CT (CPT® 75572) can be performed to evaluate the anatomy of the pulmonary veins:  Prior to an ablation procedure performed for atrial fibrillation.  Post-procedure between 3-6 months after ablation because of a 1% to 2% incidence of asymptomatic pulmonary vein stenosis.  If no pulmonary vein stenosis is present, no further follow-up imaging is required.  If pulmonary vein stenosis is present on imaging following ablation and symptoms of pulmonary vein stenosis (usually shortness of breath) are present, can be imaged at 1, 3, 6, and 12 months.  The majority (81%) of pulmonary vein stenosis remain stable over 1 year. Progression occurs in 8.8% and regression occurs in a small percentage.

Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 58 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 7. 11. 10. 6. 5. 4. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______9. 8. 3. 1. References Cardiac 2. © 2019 . https://www.aafp.org/afp/2017/0301/p303.html Home. AAFP Diagnosis. and Differential Evaluation Syncope: A. Houser R, Gauer LA, Runser . doi:10.1161/circulationaha.105.170274 - 2006;113(2):316 Circulation. Society. Autonomic American the by Endorsed Society: Rhythm Heart the With Collaboration In Foundation: Cardiology of College American the and Group; Working isciplinary Interd Research Outcomes and Care of Quality the and Stroke, and Young, in the Disease Cardiovascular Nursing, Cardiovascular Cardiology, on Clinical Councils Association Heart American the From Syncope: of Evaluation the on Statement Scientific AHA/ACCF SA. Strickberger doi:10.1001/archinternmed.2009.204. 2009;169(14):1299. Medicine. Internal of Archives Patients. Older in Episodes Syncopal in Evaluating Tests Diagnostic of Yield Atr of Follow and Procedures Policy, Personnel, for Recommendations Fibrillation: Atrial of Ablation Surgical and onCatheter Statement Consensus Expert HRS/EHRA/ECAS al. et DL, Packer J, Brugada H, Calkins doi:10.1016/j.jacc.2009.01.004 - 2009;53(17):1573 Cardiology. of College American the of Journal Hypertension. Pulmonary V Mclaughlin - doi:10.1016/s0002 - population Louis FP, Sarasin - doi:10.1016/s0735 - 2001;37(7):1921 Cardiology. of College American the of Journal disease. heart without or with syncope with patients in history of value Diagnostic al. et C, Menozzi M, Brignole P, Alboni . doi:10.1161/circulationaha.105.602250 Circulation. Syncope. PJ. Zimetbaum GJ, Shukla . doi:10.1161/01.cir.0000061951.81767.4e - 2003;107(15):2004 Circulation. Imaging. Resonance Magnetic of Use by Learned Lessons Pulmon R. Kato - Radiology,2007;243:70 imaging. MR contrast - phase with detection Noninvasive hypertension: arterial Pulmonary al. et T, Rius P, Kuschnir J, Sanz - 2010;3(12):1287 Imaging. - Sadushi C, Plank IM, Lang

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GuidelinesImaging - 2008;11(1):132 Europace. Fibrillation. ial - Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation Surgical and onCatheter Force Task (HRS) Society Rhythm Heart the of A report Up: - 2001;111(3):177 Medicine. of Journal American The study. based V, Archer SL, Badesch DB, et al. ACCF/AHA 2009 Expert Consensus Document on Document Consensus Expert 2009 ACCF/AHA al. et DB, Badesch SL, Archer V, ary Vein Anatomy in Patients Undergoing Catheter Ablation of Atrial Fibrillation: Atrial of Ablation Catheter Undergoing Patients in Anatomy Vein ary - Simonet M, Carballo D, et al. Prospective evaluation of patients with syncope: a syncope: with patients of evaluation Prospective al. et D, Carballo M, Simonet -5 9343(01)00797 -4 1097(01)01241 . All All .

Rights Reserved. Rights . doi:10.1016/j.jcmg.2010.09.013 1295. Kolici R, et al. Imaging in Pulmonary Hypertension. JACC: Cardiovascular JACC: Hypertension. Pulmonary in Imaging al. et R, Kolici . .

79. doi: 79. 132. doi:10.1093/europace/eun341 132. Published March 1, 2017. 1, March Published

2006;113(16). 10.1148/radiol.2431060477 8924 184. . . www.eviCore.com 327. Page 1928. 2010. 1619. 59 V1.0 of 92

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CD-9: Congestive Heart Failure CD-9.1: CHF – Imaging 61 CD-9.2: Palliative Care in patients with heart failure 61 CD-9.3: Myocardial Sympathetic Innervation Imaging 61

CD-9.1: CHF – Imaging  Congestive heart failure, including post-cardiac transplant failure:  An echocardiogram is generally the first study to be done after the clinical evaluation of the patient who is suspected of having heart failure.  If the ECHO is limited or does not completely answer the question, then further evaluation with MUGA, cardiac MRI or cardiac CT may be appropriate.  A stress test to assess for CAD may be appropriate. Follow stress testing guideline: CD-1.4: Stress Testing with Imaging – Indications  Arteriovenous fistula with “high output” heart failure:  CT Chest with contrast (CPT® 71260 ) and/or CT Abdomen and/or CT Pelvis with contrast (CPT® 74160 or CPT® 72193 or CPT® 74177) OR  CTA Chest (CPT® 71275 ) and/or CTA Abdomen and/or CTA Pelvis (CPT® 74175 or CPT® 72191 or CPT® 74174) OR  MRI Chest and/or MRI Abdomen and/or MRI Pelvis without and with contrast (CPT® 71552 and/or CPT® 74183 and/or CPT® 72197) OR  MRA Chest and/or MRI Abdomen and/or MRI Pelvis (CPT® 71555 and/or CPT® 74185 and/or CPT® 72198)  Right-sided congestive heart failure can be a manifestation of pulmonary hypertension or serious lung disease.  Chest CT (CPT® 71260) or chest CTA (CPT® 71275) to evaluate for recurrent pulmonary embolism

CD-9.2: Palliative Care in patients with heart failure  There are currently no widely accepted published guidelines regarding end of life care for end-stage heart failure patients who are not candidates for advanced heart failure treatments such as left ventricular assist devices, heart pumps or heart transplantation. Consideration for palliative care services should be given to such patients.

CD-9.3: Myocardial Sympathetic Innervation Imaging  In heart failure, the sympathetic nervous system is activated in order to compensate for the decreased myocardial function. Initially, this is beneficial, however, long-term this compensatory mechanism is detrimental and causes further damage.

 Markers have been developed, using radioactive iodine, in an attempt to image this increased myocardial sympathetic activity. Currently, AdreView™ (Iodine-123 meta- iodobenzylguanidine), is the only FDA-approved imaging agent available for this purpose. eviCore currently considers AdreView™ to be experimental and investigational.  The AMA has established the following set of Category III codes to report these studies: Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 61 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 6. 5. 4. 3. 2. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. References Cardiac © 2019 - 2013;6(7):772 Imaging. Cardiovascular JACC: mIBG 123I of Studies Cohort Multicenter of Analysis Pooled A al. S, et Yamashina K, Nakajima T, Nakata - 2010;55(20):2212 Cardiology. of College American the of Journal Failure. in Heart Events Cardiac and Imaging - Iodine Myocardial al. et MD, Cerqueira R, Senior AF, Jacobson . doi:10.1093/eurheartj/ehw128 - 2016;37(27):2129 Journal. Heart European failure. heart chronic and acute of and treatment diagnosis the for Guidelines ESC 2016 al. et SD, Anker AA, P, Voors Ponikowski . doi:10.1016/j.cardfail.2016.07.001 - 2016;22(9):659 Failure. Cardiac of Journal Failure. Heart of Management the for Guideline ACCF/AHA 2013 the of Update An Failure: Heart for Therapy Pharmacological on New Update Focused ACC/AHA/HFSA 2016 B, al. et Bozkurt M, Jessup CW, Yancy doi:10.1016/j.cardfail.2010.04.004 2010;16(6). Failure. Cardiac of Journal Guideline. Practice Failure Heart Comprehensive 2010 HFSA HFSO. America doi:10.1161/cir.0b013e31829e8807 - 2013;128(16):1810 Circulation. Guidelines. Practice on Force Task Association Heart Foundation/American Cardiology of College American the of A Report Summary: Executive Failure: Heart of Management the for Guideline ACCF/AHA 2013 B, al. et Bozkurt M, Jessup CW, Yancy  

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quantitative assessment 0332T quantitative assessment 0331T GuidelinesImaging I maging of Sympathetic Innervation for Assessment for Innervation Sympathetic of maging - - Myocardial sympathetic innervation imaging, planar qualitative and Myocardial sympathetic innervation imaging, planar qualitative and . doi:10.1016/j.jacc.2010.01.014 2221. . All All .

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, , withtomographic SPECT. .

. doi:10.1016/j.jcmg.2013.02.007 784. .

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CD-10: Cardiac Trauma CD-10.1: Cardiac Trauma – Imaging 64

______©2019 eviCore healthcare. All Rights Reserved. Page 63 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 5. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______4. 2. 1. References  Cardiac Trauma CD-10.1: Cardiac 3. © 2019 - 2011:190 Press; University Cambridge NY: York, New Approach. Medicine Emergency A Comprehensive Trauma: In: trauma. A. Chest Conn 1230. doi:10.1016/j.echo.2010.10.005 1230. Echocardiography of Society American of the Journal Physicians. Emergency of College American and Echocardiography of Society American the of Statement Consensus A Setting: Emergent the in Ultrasound Cardiac al. Focused et M, Bierig VE, Noble AJ, Labovitz surgeon. American The trauma. chest blunt in tomography computerized thoracic of Efficacy J. Protetch Yeaney WW, L, Omert . doi:10.1148/radiology.197.1.7568809 - 1995;197(1):125 Radiology. chest. the of CT helical with detection rupture: aortic traumatic Blunt RE. Gold MJ, PA, Graney Flick T, Fabian PG, Menke ML, Gavant  . Published March 2006. March Published . https://www.ncbi.nlm.nih.gov/pubmed/16568196 M Elie 2001.     Any of the following can be used to evaluate cardiac or aortic trauma:

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Cardiac CT (CPT CT Cardiac Chest CTA (CPT CTA Chest (CPT CCTA ( MRI Cardiac Echocardiogram (TTE, TEE) GuidelinesImaging - C. Blunt cardiac injury. The Mount Sinai journal of medicine, New York. New medicine, of journal Sinai Mount The injury. cardiac Blunt C. ® 75574) CPT . All All .

® ® 71275) ® Rights Reserved. Rights 75572) 75557, CPT . Published July Published . https://www.ncbi.nlm.nih.gov/pubmed/11450784 – Imaging ® 212.

75561, and CPT 8924 ® 75565) 133. . 2010;23(12):122 . www.eviCore.com Page 64of92 V1.0 5-

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CD-11: Adult Congenital Heart Disease CD-11.1: Congenital heart disease – General Information ...... 66 CD-11.1.1: Definitions ...... 66 CD-11.1.2: Modalities ...... 68 CD-11.1.3: Coding ...... 69 CD-11.2: Congenital Heart Disease Imaging Indications ...... 70 CD-11.2.1: ASD-Atrial septal defects ...... 70 CD-11.2.2: Anomalous Pulmonary Venous Connections ...... 71 CD-11.2.3: Ventricular Septal Defect (VSD) ...... 71 CD-11.2.4: Atrioventricular Septal Defect (AV Canal, AVSD, endocardial cushion defect) ...... 72 CD-11.2.5: Patent Ductus Arteriosus (PDA) ...... 72 CD-11.2.6: Cor Triatriatum ...... 72 CD-11.2.7: Congenital Mitral Stenosis ...... 73 CD-11.2.8: Subaortic Stenosis (SAS) ...... 73 CD-11.2.9: Congenital Valvular Aortic Stenosis ...... 74 CD-11.2.10: Aortic disease in Turner Syndrome ...... 75 CD-11.3: Aortopathies with CHD ...... 75 CD-11.3.1: Supravalvular Aortic Stenosis ...... 75 CD-11.3.2: Coarctation of the Aorta ...... 76 CD-11.3.3: Valvular Pulmonary Stenosis ...... 77 CD-11.3.4: Branch and Peripheral pulmonary stenosis ...... 77 CD-11.3.5: Double chambered RV ...... 78 CD-11.3.6: Ebstein Anomaly ...... 78 CD-11.3.7: Tetralogy of Fallot (TOF, VSD with PS) ...... 78 CD-11.3.8: Right Ventricle-to-Pulmonary Artery Conduit ...... 79 CD-11.3.9: Transposition of the great arteries (TGA) ...... 79 CD-11.3.10: Congenitally corrected TGA ...... 80 CD-11.3.11: Fontan Palliation of Single Ventricle Physiology ...... 80 CD-11.3.12: Severe Pulmonary artery hypertension (PHT) and Eisenmenger syndrome ...... 81 CD-11.3.13: Coronary artery anomalies ...... 81 CD-11.4: Pregnancy – Maternal Imaging ...... 81

______©2019 eviCore healthcare. All Rights Reserved. Page 65 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  CD-  CongenitalCD-11.1: heart disease Cardiac © hypertension Pulmonary Arrhythmias hypoxemia Cyanosis/ dysfunction pulmonary hepatic Renal limitation capacity Exercise enlargement Aortic Valvar sequelae anatomic or Hemodynamic Characteristics 2019 NYHA functional functional NYHA  classification CHD Anatomic  C, D) B, (A, stages Physiological    disorders please see the condition This section covers adult congenital heart disease 11.1.1: 11.1.1:

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class   I Class Each congenital heart lesion is divided i Bicuspid aortic valve ( Hypertrophic cardiomyopathy ( Marfan GuidelinesImaging

 Repaired conditions    Native disease

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Mild isolated pulmonic stenosis Isolated small VSD Isolated small ASD Definitions Simple Syndrome

None None None None Normal None None None . All All .

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BAV)

treatment requiring not Arrhythmia limitation cardiac objective Abn Mild Mild shunt small dysfunction, of enlargement ventricular Mild HCM specific sections ormal ormal

– General ) Physiological stage B II

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          III Class  Class II Class GuidelinesImaging

crisscross heart, isomerism, heterotaxy syndromes, ventricular inversion) Other abnormalities of atrioventricular and ventriculoarterial connection (i.e., Truncus arteriosus TGA (classic d or TGA Pulmonary atresia (all forms) single ventricle) hypoplastic left heart, any other anatomic abnormalitywith a functionally Single ventricle (including double inlet left ventricle, tricuspid atresia, atresia Mitral Interruptedaortic arch Fontan procedure Double- Cyanoticcongenital heartdefect(unrepaired palliated, or all forms)                        Repairedunrepaired or   VSD with associated abnormality and/or moderate or greater shunt Repaired tetralogy of Fallot Straddling atrioventricular valve Supravalvar aortic stenosis guidelines) Subvalvar aortic stenosis (excluding HCM; HCM not addressed in these Sinus venosus defect Sinus of Valsalva fistula/aneurysm Peripheral pulmonarystenosis Pulmonary valve stenosis (moderate or greater) Pulmonary valve regurgitation (moderate or greater) Moderate and large persistently patent ductus arteriosus Moderate and large unrepaired secundum ASD Ostium primum ASD Infundibular right ventricular outflow obstruction variations) Ebstein anomaly (disease spectrum includes mild, moderate, and severe Coarctation of the aorta Congenital mitral valve disease Congenital aortic valve disease AVSD (partial or complete, includingprimum ASD) Anomalous aortic origin of a coronary artery from the opposite sinus Anomalous coronary artery arising the from pulmonary artery Anomalous pulmonary venous connection, partial or total Aorto residual shunt or chamber enlargement Repaired secundum ASD or sinus venosus defect without significant Repaired VSD without significant residual shunt or chamber enlargement - - Moderate Complexity Great Complexity (or Complex) outlet ventricle - left ventricular fistula ventricular left . All All .

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TGA; CCTGA or l

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Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD-11.1.2: Modalities  Echocardiogram- transthoracic (TTE) or transesophageal (TEE)  Transthoracic echocardiography (TTE) is an indispensable tool in the initial and serial follow-up evaluation to identify abnormalities and changes that commonly influence management decisions.  Cardiac MRI (CMR)  CMR plays a valuable role in assessment of RV size and function, because it provides data that are reproducible and more reliable than data obtained with alternative imaging techniques  For intracardiac congenital heart disease, CMR will typically include flow velocity mapping for shunts and flow assessment.  Imaging that only requires aortic arch imaging, does not require intracardiac CMR, only chest MRA.  Cardiac Computed Tomography (CCT) and Cardiac Computed Tomography Angiography (CCTA)  The most important disadvantage of CCT (including CT angiography) as an imaging technique is the associated exposure to ionizing radiation.  Cardiac catheterization  (hemodynamic and/or angiographic) in patients with adult CHD AP classification II and III, or interventional cardiac catheterization in patients with adult CHD AP classification I to III should be performed by, or in collaboration with, cardiologists with expertise in adult CHD  Exercise Testing  Exercise test does not imply stress imaging  Stress Imaging  Includes-MPI, stress echo, stress MRI  PET stress may be included as per CD-6  Circumstances where CMR, CCT, TEE, and/or Cardiac Catheterization may be Superior to TTE  Assessment of RV size and function in repaired Tetralogy of Fallot (TOF), systemic right ventricles, and other conditions associated with right ventricular

(RV) volume and pressure overload  Identification of anomalous pulmonary venous connections  Serial assessment of thoracic aortic aneurysms, especially when the dilation might extend beyond the echocardiographic windows  Accurate assessment of pulmonary artery (PA) pressure and pulmonary vascular resistance  Assessment for re-coarctation of the aorta  Sinus venosus defects  Vascular rings Cardiac Imaging

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______f Routine   CD-  CHD with Aortopathies CD-11.3:    CD- Cardiac  © CMR TTE Physiolo Modality 2019      N  studies Initial hypercholesterolemia. commonly in patients with syndromeWilliams or homozygous familial Supravalvular aortic stenosis is a relatively rare condition overall but is seen heart syndrome ( Fallot postoperative procedur Dilated aortic arches are not uncommon with several congenital heart disease and    Surveillance   studies Initial more common and my not be reliably seen on echocardiogram Dissection more common for agiven aortic diameter 

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Cardiac Imaging Cardiac Imaging Guidelines V1.0

CD-11.3.3: Valvular Pulmonary Stenosis  Overview Initial studies-Diagnosis, clinical changes, consideration of surgery  Echocardiogram (TTE) at time of diagnosis  For issues affecting management not well visualized on TTE  Cardiac MRI or cardiac CT  Chest MRA or chest CTA  Valvular PS routine follow-up and testing.  Echocardiogram-stages  Mild PS – peak gradient <36 mmHg (peak velocity < 3m/s)  Moderate PS- peak gradient 36-64 mmHg (peak velocity 3-4 m/s)  Severe PS- peak gradient >64 mmHg (peak velocity > 4 m/s); or mean gradient >35 mmHg.  Routine stress imaging is not required  Routine chest or cardiac or ischemia workup not required.

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CD-11.3.4: Branch and Peripheral pulmonary stenosis  Overview  Can be seen in newborns as a normal variant in the first 6 months of life  Can be seen in surgeries of right ventricular outflow (TOF)  Noonan  Alagille  Williams  Maternal rubella exposure  Keutel syndrome  Initial studies-Diagnosis, clinical changes, consideration of surgery  Echocardiogram (TTE) at time of diagnosis  Baseline chest MRA or chest CTA  Cath may be considered if other advanced imaging is not adequate for management  VQ scan or chest MRA for differential blood flow Cardiac Imaging

______©2019 eviCore healthcare . All Rights Reserved. Page 77 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______   CD- fo Routine  CD- follow Routine  CD- Cardiac © cardiac CT cardiac MRI Cardiac Echo ( stage Physiological Modality Echo ( stage Physiological Modality CTA chest MRAChest or CT cardiac or MRI Cardiac TTE stage Physiological Modality 2019   Prior to cardiac intervention or surgery     studies Initial Includes    Overview Initial studies  studies Initial

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        pregnancy,childbirth andthe puerperium. intensive specialist cardiac and obstetric monitoring needed throughout severe morbidity. Expert counseling required. If pregnancy is decided upon, WHO classification III: significantly increased risk of maternal mortality or      II classification WHO   increase in morbidity. WHO classification II: small increase in maternal risk mortality or moderate     be discussed. If pregnancy continues, care as for classWHO III. morbidity; pregnancy contraindicated. If pregnancy occurs, termination should WHO classification IV: extremely high risk of maternal mortality or severe      Patent D Uncomplicated small or mild pulmonary stenosis Aortic dilation 40 dilation Aortic Other complex congenital heart dis Unrepaired cyanotic heart disease Fontan circulation Systemic right ventricle Mechanical valve Repaired coarctation Aorta <45 mm in association with bicuspid aortic valve disease sy Marfan Native or tissue valvular heart disease not considered I orWHO IV Mild left ventricular impairment Unrepaired tetralogy of Fallot Unrepaired atrial or ventricular septal defect patent ductus arteriosus, anomalous pulmonaryvenous connection) Successfully repaired simple lesions (atrial or ventricular septal defect, Mitral valve prolapse class III class Severe systemic ventricular dysfunction (LVEF <30%, NYHA functional Pulmonary arterial hypertension from any cause 45 dilation Aortic Native severe coarctation of the aorta valve Aortic dilation >50 mm in aortic disease associated with bicuspid aortic Marfan syndrome with aorta dilated >45 mm Severe mitral stenosis; severe symptomatic aortic stenosis

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Cardiac Imaging 11. 10. 12. 13. 9. 8. 7. 6. 5. 4. 2. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______16. 14. 3. 1. References Cardiac 15. © 2019 . doi:10.1016/j.jvs.2017.10.044 Surgery Vascular of Journal aneurysm. aortic abdominal an with patients of care the on guidelines practice Surgery Vascular for Society The al. et MK, Eskandari RL, EL, Dalman Chaikof doi:10.1161/cir.0000000000000311 Tachycardia. Supraventricular With Patients Adult of Management the for Guideline ACC/AHA/HRS 2015 al. et MA, Caldwell JA, Joglar RL, Page Circulation Society. Rhythm Heart the and Guidelines Practice onClinical Force Task Association Heart Cardiology/American of College American the of Report A Syncope: With Patients of Management Shen W Shen doi:10.1161/hyp.0000000000000065. 2018;71(6). . Hypertension Guidelines. Practice onClinical Force Task Association Heart Cardiology/American of College ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM 2010 al. et JA, Beckman GL, Bakris LF, Hiratzka https://www.cardiovascular.abbott/us/en/hcp/products/structural Cardiovascular. Abbott Device. Closure PFO Occluder: PFO AMPLATZER doi:10.1161/cir.0b013e3181d4739e. Circulation Disease. Aortic Thoracic With Patients of Management Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report A Adults: in Pressure Blood High of Management and Evaluation, Detection, Prevention, the for Guideline ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA al. et 2017 WS, Aronow RM, Carey PK, Whelton - 2017;27(10):1872 Iteration of the International Classification of Diseases (ICD Diseases of Classification International the of Iteration Eleventh the and (IPCCC) Code Cardiac Congenital and Paediatric International the disease: cardiac paediatric and congenital for Nomenclature al. et SD, Colan MJ, Béland RCG, Franklin . 2013;2(6). doi:10.1161/jaha.113.000424 2013;2(6). . Association Experience. Population Multicenter An Unselected Closure: El Echocardiography of Society American of the Journal Interventions. and Angiography Cardiac for Society Echocardiograph of Society American the From Ovale: Foramen Patent and Defect Septal Atrial of Assessment Echocardiographic the for al. Guidelines et LB, Armsby MS, Cohen FE, Silvestry doi:10.1161/cir.0000000000000603 Guidelines. Practice onClinical Force Task Association Heart Cardiology/American of College American the of Report A Disease: Heart Congenital With Adults of Management the for Guideline AHA/ACC 2018 al. et JA, Aboulhosn CJ, Daniels KK, Stout Administration. and Drug Food U.S. Panel. Devices System Circulatory the of Materials Meeting 2018 Health. Radiological and Devices for Center Journal of Nuclear Cardiology Nuclear of Journal Disease. Heart Nonvalvular in Function and Structure Cardiac of Assessment in the Imaging Multimodality for Criteria Use Appropriate 2019 ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS P. Soman P, Schoenhagen R, S, Mehran Kort JU, Doherty . lationaha.115.019987 doi:10.1161/circu 1746. Defects Septal Atrial of Closure Transcatheter Following Erosion Cardiac for Factors Risk Relative Z. E, Amin Alboliras D, Kenny MD, Quartermain DB, Mcelhinney panel committees/circulatory (ASO) Occluder Septal Atrial Amplatzer the with Erosion concerning (IFU) Use for Instructions to Updates Ex efficacy. and safety occluder: ovale foramen patent Amplatzer B. Meier F, Praz A, R, Wahl Madhkour Administration Drug and Food (CDRH) Health Radiological and Devices for Center Evaluation Device of Occluder (PFO) Ovale Foramen Patent AMPLATZER A. Drummond ‐

pert Review of Medical Devices Medical of pert Review Said HG, Bratincsak A, Foerster SR, et al. Safety of Percutaneous Patent Ductus Arteriosus Ductus Patent Percutaneous of Safety al. et SR, A, Foerster Bratincsak HG, Said eviCore healthcare eviCore

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. 2016;133(14). . Circulation - meeting . doi:10.1080/17434440.2019.1581060 182. https://www.fda.gov/advisory .

Guidelines for the Diagnosis and Diagnosis the for Guidelines . 2019;139(14). . Circulation - 007/s12350 doi:10.1 1413. - 8924 Journal of the American Heart American the of Journal 11). 11). materials - heart/amplatzer Cardiology . in Young the Cardiology . Circulation . . 2010;121(13). . : FDA Review of P120021 Office P120021 of Review FDA - circulatory - 2016;133(18):1738 . - - pfo.html - system www.eviCore.com

. 2018;67(1). . of the American the of - 019 Page - . devices -7. 01751 y and 84 and V1.0 of - 92

Cardiac Imaging 18. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______20. 19. 17. Cardiac 21. 23. 22. 25. 24. 26. 28. 27. 29. 30. © 2019 syndromes. EPEuropace syndromes. arrhythmia primary inherited with patients of and management diagnosis onthe statement consensus expert HRS/EHRA/APHRS summary: Executive al. et M, Horie AA, SG, Wilde Priori doi:10.1161/cir.0000000000000134. ning_Erosion_with_the_Amplatzer_Atrial_Septal_Occluder_ASO.html t_Recalls/Dear_Healthcare_Professional_Letters/2013/Updates_to_Instructions_for_Use_IFU_concer https://www.hsa.gov.sg/content/hsa/en/Health_Products_Regulation/Safety_Information_and_Produc doi:10.1161/jaha.117.007146. 2018;7(12). . Association Heart American the of Journal Disorders. Other and Prevention Stroke for Closure Ovale Foramen Patent CJ. Kavinsky H, Jneid JJ, Murphy MF, Poulin FMS, Collado Cardiology of College American EA, Landzber Bradley CJ, Daniels – Non With Patients of Management the for Guideline AHA/ACC 2014 al. et RG, Brindis NK, EA, Wenger Amsterdam 2014;30(10). doi:10.1016/j.cjca.2014.09.002. 2014;30(10). Di Heart Congenital in Adult Arrhythmias of Management and Recognition the on Statement Consensus Expert PACES/HRS al. S, et Balaji GFV, P, Hare Khairy Cardiovascular Evaluation and Management of Patients of andManagement Evaluation Cardiovascular Perioperative on Guideline ACC/AHA 2014 al. et AD, Auerbach KE, Fleischmann LA, Fleisher Cardiology of College - doi:10.1183/13993003.01032 Journal Respiratory European hypertension. pulmonary of Cardiology of College American the of Management Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the on Guideline ACC/AHA/HRS 2018 al. et C, Barrett MH, Schoenfeld FM, Kusumoto iology Card of College American the of Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Adults With of Management in the Replacement Valve Aortic Transcatheter for Pathway Decision Consensus Expert ACC 2017 al. et KP, Alexander DJ, Kumbhani CM, Otto J Vachiery M, Humbert N, Galiè doi:10.1016/j.jacc.2012.11.019. Cardiology of College American the of Journal Infarction. Myocardial Elevation ST of Management the for Guideline ACCF/AHA 2013 al. et DD, Ascheim FG, Kushner PT, O'gara doi:10.1016/j.jacc.2018.08.1029. Disease. Heart Congenital With Adults of Management the for Guideline AHA/ACC 2018 al. et JA, Aboulhosn CJ, Daniels KK, Stout doi:10.1161/cir.0b013e3181d4739e. Circulation Disease. Aortic Thoracic With Patients of Management and Diagnosis the for Guidelines ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM 2010 al. et JA, Beckman GL, Bakris LF, Hiratzka of the American College of Cardiology of College American the of S PG, Pieper S, Goland U, Elkayam - 2010;31(23):2915 Journal Heart European (ESC). Cardiology of Society European the of Disease Heart Congenital congenit grown - of management the for Guidelines ESC al. et NMSD, P, Groot Bonhoeffer H, Baumgartner

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Patients With Bradycardia and Cardiac and Bradycardia With Patients 2957. doi:10.1093/eurheartj/ehq249. 2957. ST . 2018. doi:10.1016/j.jacc.2018.10.044. 2018. . . All All . - Elevation Acute Coronary Syndromes. Circulation Syndromes. Coronary Acute Elevation

- 2013;15(10):1389 . Rights Reserved. Rights 2015. - 2017;70(25):3173 . - Journal of the American College of Cardiology of College American the of Journal L, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment and diagnosis the for Guidelines ESC/ERS 2015 al. et L, - Fontan al. et MJ, g . 2014;64(22). doi:10.1016/j.jacc.2014.07.944. 2014;64(22). . ilversides CK. High CK. ilversides - 2017;69(10):1313 . . 2016;68(4):396 .

1406. doi:10.1093/europace/eut272. 1406. 3194. doi:10.1016/j.jacc.2017.10.045. 3194. Associated Liver Disease. Disease. Liver Associated - -

410. doi:10.1016/j.jacc.2016.05.048. 410. Journal Delay. Conduction Risk Cardiac Disease in Pregnancy. Journal Pregnancy. in Disease Cardiac Risk al of al Journ Surgery. Noncardiac Undergoing - 2015;46(4):903 . 1346. doi:10.1016/j.jacc.2016.12.006. 1346. 8924 sease. sease. . 2010;121(13). . Canadian Journal of Cardiology of Journal Canadian . . 2014;130(25). . 975. . 2013;61(4). . . 2018;73(12). . Journal of the of Journal

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CD-12: Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD) CD-12.1: Oncologic Indications for Cancer Therapeutics – Related Cardiac Dysfunction (CTRCD) 87

______©2019 eviCore healthcare. All Rights Reserved. Page 86 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______References  Practice Note  (CTRCD) Dysfunction Cardiac .1: CD-12 Cardiac 4. 2. 1. 3. © 2019 professionals/medicines/herceptin. (trastuzumab) - breast cancer:theM.D.AndersonCanc medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723407. Publis doi:10.1161/circ Appropriate UseCriteriaforCardiacRadionuclideImaging. Circulation.2009;119(22). 24:4107-4 Genentech: Herceptin Guarneri V,LenihanDJ,Valeroetal.Long-t Broder H,GottliebRA,LeporNE.Chemotherapyandcardiotoxicity.Reviewsinc Hendel RC,BermanDS,CarliMFD,etal.ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009      chemotherapy: Advantages of Echocardiography in comparison to MUGA in patients oncardiotoxic     related indicati and wall motion analysis are appropriate for any of the following chemotherapy If an echocardiogram is not appropriate, MUGA evaluation of LV ejection fraction

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the right heart May allow visualization of a clot or tumor in the Inferior Vena Cava (IVC) and/or Allowsestimate of pulmonarypressure Allowsview the of pericardium to look for No IV access required when echo contrast is not used No ionizing radiation described previously in CD- determination of LVEF and/or wall motion EXCEPT in one of the circumstances eviCore guidelines support using MUGA than echocardiography rather in (LVEF) Echocardiography vs. MUGA for Determining Left Ventricular Ejection Fraction at appropriate intervals. If the LVEF is < 50% on echocardiogram than follow upcan be done with MUGA   drugs. Determine LV function in patients in patients on cardiotoxic chemotherapeutic GuidelinesImaging

significant left ventricular cardiac dysfunction May repeat every 4weeks if cardiotoxic baseline and at every 6weeks. The time frame should be determined by the provider, but no more often than – Therapeutics Cancer for Indications logic Onco 115. Do

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CD-13: Pre-Surgical Cardiac Testing CD-13.1: Pre-Surgical Cardiac Testing – General Information 89 CD-13.2: Primary Cardiac Surgery – No Previous Cardiac Surgery 89 CD-13.3: Re-operative cardiac surgery 89 CD-13.4: Minimally Invasive Aortic Valve Surgery 90 CD-13.5: Percutaneous Mitral Valve Repair (mitral valve clip) 90

______©2019 eviCore healthcare. All Rights Reserved. Page 88 of 92 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ Re CD-13.3:  PrimaryCD-13.2:    Pre-SurgicalCD-13.1: Cardiac T Cardiac © 2019 tests for preoperative assessment: Patients undergoing re    documented high risk for aortic calcification including any o aortic calcifications may beindicated prior to primary cardiac surgerywhen there is CT Chest without contrast  surgery. associated with lower postoperative stroke rates and mortality after primary cardiac postoperative stroke. Aortic contrast load the patient prior to placing them onthe heart insufficiency, the provider might chose to forgo the contrast if does not want to these studies to delineate the anatomic structures. However, in patients with renal grafts and lower rates of postoperative stroke. decreased incidence of intraoperative injury to heart, great vessels and prior bypass cardiopulmonary bypass before re- vascular exposure, and alternative cannulation sites and for establishing be used to change the operative strategy including non- sternum, and to assess for the location of prior bypass grafts. Information can then location of the various cardiac chambers and great vessels and proximity to the calcifications, to evaluate the anatomic relationships in the mediastinum, such as the re In    surgery according to type of procedure planned: It is important to differentiate requests for preoperative CT imaging before cardiac

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End stage renal disease (dialysis) stenosis aortic Calcific Aortic calcification on chest x   to CT percutaneous tricuspid and TMVR which will other percutaneous valve procedures (such as valve in valve aortic or mitral, operations, minimally invasive or robotic mitral operations, TAVR, Mitraclip or M appropriate for the pre- determine R Primary cardiac operation —individ GuidelinesImaging -

edo procedures inimally invas inimally : : operative cardiac surgery, the benefit of preoperative CT is to assess aorticfor atherosclerosis is recognized as the single most important determinant of C Visualize the extent and location of aortic atherosclerosis chest hange the operative strategy such as those problematic areas are avoided 2,10,20,24 -operativecardiac surgery

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Cardiac Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______    CD-13.5:     MinimallyCD-13.4: Invasive Aortic Valve Surgery Cardiac © 2019    Post procedure t indicated. Because this is avenous approach, CTA of abdomen, chest, and/or pelvis not is    procedure: The fol should include, if indicated, cardiac resynchronization therapy. secondary mitral regurgitation who have failed optimal medical therapy. This therapy surgical risks are prohibitive, as well as symptomatic moderate to severe or severe symptomatic, moderate to severe or severe primary mitral regurgitation whose anterior and posterior mitral valve leaflets. It is indicated for patients with edge- access to apply aclip device ( Percutaneous treatment of mitral regurgitation can be accomplished using venous CT chest and CT abdomen and pelviswith contrast ab CTA chest, CTA procedure planning. preoperative assessment of patient suitability for the approach and for subsequent invasive or robotic mitral valve surgery For patient undergoing minimally invasive aortic valve surgery and minimally See    

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One year Six months One month Heart catheterization, including right heart cath if requested Transesophageal echo with or without 3D rendering Transthoracic echo with or without 3D rendering approved routinely. CT heart usually does not provide the necessary information, and should not be CCTA will not show the extent of the thoracic aorta that needs to be visualized) CCTA only prior if CABG (this might be in addition to CT with IV contrast as CTA chest CT chest with IV contrast GuidelinesImaging CD- to lowing imaging may be used to determine if a patient is eligible thefor

- Percutaneous Mitral Valve Repair (mitral valve clip) Percutaneous valve (mitral Valve Repair Mitral edge mitral leaflet coaptation, approximating opposing sections of the 4.8: TranscatheterAortic Valve Replacement (TAVR)

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Cardiac Imaging 10. 9. 11. 3. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 12. 8. 7. 5. 4. 2. ______1. References Cardiac 15. 14. 13. 6. 16. 18. 17. © 2019 - Jun;12(6):919 in stroke perioperative of risk al et Jr, JN Irvine G, Ailawadi DJ, Lapar Hazra JR, Inacio F, Erthal doi:10.1016/j.rcl.2009.09.002. S in stroke of prevention for tomography computed chest needs Y. Who Miyamoto S, Fukui M, Ryomoto H, Tanaka M, Mitsuno H, Nishi - Jul;38(1):131 2001 Cardiol. Coll Am J aorta. ascending the in disease atherosclerotic of extent and location the to al et P, Bergman L, Hadjinikolaou J, Linden der van 10.1016/j.atherosclerosis.2004.03.027. - Sep;176(1):133 2004 Atherosclerosis. calcifications. aorta thoracic and coronary between correlation close of evidence tomography computed Spiral al. et J, Shemesh EZ, Y, Fisman Adler surgery cardiac before tomography computed of Effect al. et RC, Meijer LM, de Heer AM, den Harder J making. al et AM, P, Gillinov S, Schoenhagen Moodley - May;33(3):156 2018 Imaging. Thorac J Surgery. Cardiac - 2017;25(4):659 Surgery. Thoracic and CardioVascular Interactive surgery? cardiac primary undergoing patients in utility clinical provide imaging tomography computed preoperative routine Does A. Markowitz S, Deo K, Chen A, Merlo - 2018;155(5):2041 Surgery. Cardiovascular and Thoracic of Journal The tomography. computed and ultrasonography, lung radiography, Chest exploring of ways and importance The M. Cantinotti doi:10.1510/icvts.2008.189506. - Jul;9(1):119 2009 Surg. Thorac Cardiovasc Interact surgery? cardiac 2010Jan;48(1):117 Am. North Clin Radiol patients. surgery cardiac of assessment in the tomography computed Multidetector RC. Gilkeson AH, Markowitz NJ, Akhtar Surgery. Valve Mitral Invasive Minimally for Evaluation Tomography Computed Preprocedural TS. Guy RM, Steiner SA, Simpson C, Dass doi:10.1016/j.ejrad.2016.01.003. - Apr;85(4):744 2016 Radiol. J Eur stroke. and mortality strategy, on surgical angi Khan NU, Yonan N. Does preoperative computed tomography reduce the risks the reduce tomography computed preoperative Does N. Yonan NU, Khan doi:10.1097/rti.0000000000000170. Surgery graphy. tomo computed using aorta ascending calcified severely clamping for approach Y. Comprehensive Miyamoto M, Ryomoto M, Mitsuno H, Nishi - Jul;84(1):38 2007 Surg. Thorac Ann emboli. aortic potential identifies al et AC, Polimenakos N, Matsutani Lee R, doi:10.1532/hsf98.20033009. 2004;7(3). . Forum Surgery Heart The Aorta? Ascending the of Atherosclerosis of Diagnosis the for Ultrasound Epiaortic Intraoperative or Tomography Computed Preoperative M. Öhman K, Forsberg JVD, Linden P, Bergman - 2017;70(19):2421 - 2005;79(2):589 Management Tomography trial. randomized a of multicenter anddesign Rationale x chest conventional to alternative an as reconstructions Surger Heart Reoperative in Tomography Computed Multidetector Cardiac on Based Planning Surgical of Modification A, al. et Kramer R, Sharony G, Aviram O'gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC Expert Consensus Decisi Consensus Expert ACC 2017 al. et V, Badhwar PA, Grayburn PT, O'gara - Maurovich LMD, Heer AMD, Harder - Jul;11(1):30 2010 urg.

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ography for planning of minimally invasive robotic mitral valve surgery impact ondecision impact surgery valve mitral robotic invasive minimally of planning for ography GuidelinesImaging - 2010;10(1):18 . - Aug;146(2):262 2013 . Surg Cardiovasc Thorac - 2016;10(3):242 .

Journal of the American College of Cardiology of College American the of Journal Regurgitation. Mitral of 5. 23. doi:10.1510/icvts.2010.265165. 23.

595. doi:10.1016/j.athoracsur.2004.07.012. 595. - doi:10.1016/s0735 2449. doi:10.1016/j.jacc.2017.09.019. 2449. . All All .

20. doi:10.1510/icvts.2009.216242. 20. 3. doi:10.1510/icvts.2009.231761. 3. S, Chan V, Chow BJW. Cardiac Computed Tomography Computed Cardiac BJW. V, Chow S, Chan Rights Reserved. Rights reoperative cardiac surgery. Interact Cardiovasc Thorac Surg. 2011 Surg. Thorac Cardiovasc Interact surgery. cardiac reoperative 245. doi:10.1016/j.jcct.2016.01.016. 245. 662. doi:10.1093/icvts/ivx098. 662. - 1097(01)01328 Horvat P, et al. Ultra low Ultra al. et P, Horvat Preoperative . - 2015;30(6):386 . Imaging Thoracic of Journal Preoperative . 2042. doi:10.1016/j.jtcvs.2018.01.032. 2042.

. Preoperative multidetector computed tomograpy computed multidetector Preoperative . . Postoperative stroke in cardiac surgery is related is surgery in cardiac stroke Postoperative . 6. the entire chest before and after cardiac surgery: cardiac after and before chest entire the computed tomography is associated with lower with associated is tomography computed Journal of Cardiovascular Computed Cardiovascular of Journal cardiac surgery? Interact Cardiovasc Thorac Cardiovasc Interact surgery? cardiac Interactive CardioVascular andThoracic CardioVascular Interactive - ray prior to hear to prior ray 167. trast chest computed tomography computed chest trast noncon 8. 8924

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