CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Appropriate Use Criteria: Imaging of the Heart EFFECTIVE SEPTEMBER 12, 2021 Proprietary Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details. AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein. 8600 West Bryn Mawr Avenue Appropriate.Safe.Affordable South Tower – Suite 800 Chicago, IL 60631 © 2017 ©©©© 2021 AIM Specialty Health www.aimspecialtyhealth.com CAR01-0921.2 Imaging of the Heart Table of Contents CLINICAL APPROPRIATENESS GUIDELINES ..................................................................................................................... 1 Table of Contents ............................................................................................................................................................... 2 Description and Application of the Guidelines ............................................................................................................... 4 General Clinical Guideline ................................................................................................................................................ 5 ADVANCED CARDIAC IMAGING ........................................................................................................................................... 7 Cardiac CT with Quantitative Evaluation of Coronary Calcification .................................................................................. 7 Codes .................................................................................................................................................................................. 7 General Information ........................................................................................................................................................... 7 Clinical Indications ............................................................................................................................................................ 8 References ......................................................................................................................................................................... 9 Cardiac CT for Structure and Morphology ......................................................................................................................... 10 Codes ................................................................................................................................................................................ 10 General Information ......................................................................................................................................................... 10 Clinical Indications .......................................................................................................................................................... 11 References ....................................................................................................................................................................... 13 Coronary CT Angiography (CCTA) and CT Derived Fractional Flow Reserve (FFR-CT) ................................................ 15 Codes ................................................................................................................................................................................ 15 General Information ......................................................................................................................................................... 15 Clinical Indications .......................................................................................................................................................... 16 References ....................................................................................................................................................................... 18 MRI Cardiac .......................................................................................................................................................................... 22 Codes ................................................................................................................................................................................ 22 General Information ......................................................................................................................................................... 22 Clinical Indications .......................................................................................................................................................... 22 References ....................................................................................................................................................................... 25 PET Myocardial Imaging ...................................................................................................................................................... 28 Codes ................................................................................................................................................................................ 28 General Information ......................................................................................................................................................... 28 Clinical Indications for PET Perfusion Imaging ............................................................................................................ 30 Clinical Indications for Metabolic PET Imaging ............................................................................................................ 35 References ....................................................................................................................................................................... 36 NUCLEAR CARDIOLOGY .................................................................................................................................................... 38 Myocardial Perfusion Imaging ............................................................................................................................................ 38 Codes ................................................................................................................................................................................ 38 General Information ......................................................................................................................................................... 38 Clinical Indications .......................................................................................................................................................... 40 References ....................................................................................................................................................................... 45 Infarct Imaging ..................................................................................................................................................................... 48 Codes ................................................................................................................................................................................ 48 General Information ......................................................................................................................................................... 48 © 2021 AIM Specialty Health. All rights reserved. 2 Imaging of the Heart Clinical Indications .......................................................................................................................................................... 48 References ....................................................................................................................................................................... 49 Cardiac Blood Pool Imaging includes MUGA and First Pass Radionuclide Ventriculography ..................................... 50 Codes ................................................................................................................................................................................ 50 General Information ......................................................................................................................................................... 50 Clinical Indications .......................................................................................................................................................... 51 References ....................................................................................................................................................................... 53 ECHOCARDIOGRAPHY ....................................................................................................................................................... 55 Resting Transthoracic Echocardiography (TTE) ............................................................................................................... 55 Codes ................................................................................................................................................................................ 55 General Information ........................................................................................................................................................