Oct-Nov 00 Part A Bulletin - Medicare

LOCAL AND FOCUSED MEDICAL REVIEW POLICIES
78472: Cardiac Blood Pool Imaging
Policy Overview: The “Coding Guidelines” and the “ICD-9-CM Codes that Support Medical Necessity” sections of the
policy has been revised to include additional guidelines affected by the implementation of the 2001 ICD-9-CM update.
Policy Number
78472
Contractor Name
First Coast Service Options, Inc.
Contractor Number
090
Contractor Type
Intermediary
LMRP Title
Cardiac Blood Pool Imaging
AMA CPT Copyright Statement
CPT codes, descriptions, and other data only are
copyright 1998 American Medical Association (or such
other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply.
HCFA National Coverage Policy
N/A
Primary Geographic Jurisdiction
Florida
Secondary Geographic Jurisdiction
N/A
HCFA Region
Region IV
HCFA Consortium
Southern
Policy Effective Date
03/15/2000
Revision Effective Date
10/01/2000
Revision Ending Effective Date
09/30/2000
Policy Ending Date
N/A
LMRP Description
Radionuclide ventriculography is one of the most
widely used techniques for evaluating ventricular function.
This essentially noninvasive method of assessing ventricular
function can be easily performed and provides a
reproducible, accurate evaluation of both right ventricular
and left ventricular function. Currently, there are two
techniques for assessment of ventricular performance using
radionuclides: the first-pass technique and gated blood pool
imaging. Information that can be derived from these studies
include assessment of left and/or right ventricular ejection
fraction, regional wall motion, left ventricular volumes, and
diastolic function.
Gated blood pool imaging (multigated acquisition, or
MUGA), also known as equilibrium radionuclide
angiocardiography, is the most widely used technique to
assess ventricular function. In this technique, the patient’s
erythrocytes are labeled with technetium-99m and the
imaging is performed by synchronizing acquisition to the R
wave of the electrocardiogram (ECG). Sampling is
performed repetitively over several hundred heartbeats with
physiological segregation of nuclear data according to
occurrence within the cardiac cycle.
First-pass radionuclide angiocardiography utilizes a
high-count-rate gamma camera and involves sampling for
only seconds during the initial transient of the technetium-
99m bolus through the central circulation. The highfrequency
components of this radioactive passage are
recorded and analyzed quantitatively. After data acquisition,
right and left ventriculograms are constructed from which
ejection fractions and ventricular volumes can be calculated.
Indications and Limitations of Coverage
and/or Medical Necessity
Florida Medicare will consider cardiac blood pool
imaging studies medically reasonable and necessary for the
following indications:
• Evaluation of a patient with suspected or known
Coronary Artery Disease (CAD). A radionuclide
ventriculogram assists in stratifying patients into low
and high risk, thereby providing prognostic value.
However, perfusion imaging is superior to exercise
radionuclide ventriculograms. Therefore, current
practice is to perform stress myocardial perfusion
imaging in patients with suspected CAD.
• Evaluation of a patient after a Myocardial Infarction
(MI). Assessment of the impact of the MI on
ventricular function, identification of the physiologic
importance of coronary stenosis outside the infarct
distribution (i.e., extent in which viable myocardium is
jeopardized), and risk stratification for future cardiac
events is determined. Normally, a resting study is
recommended.
• Assessment of right ventricular function, especially in
patients with cor pulmonale or an acute inferior MI
caused by right ventricular infarction.
• Evaluation and monitoring of a patient with dilated or
hypertrophic cardiomyopathy. Restrictive
cardiomyopathy is normally diagnosed with other
noninvasive methods, therefore, radionuclide studies do
not have a role in the diagnosis of restrictive
cardiomyopathy.
• Evaluation of a patient with suspected or known
valvular heart disease to determine ventricular function
and estimate the degree of valvular regurgitation. Serial
evaluations may be necessary in patients with
asymptomatic aortic regurgitation to determine surgical
timing. In addition to obtaining a resting left ventricular
ejection fraction (usually by the gated blood pool
technique) in the timing of surgery, exercise duration is
also a key indicator.
• Evaluation and management of a patient with congestive
heart failure. The most important imaging procedure is
two-dimensional echocardiography, which can evaluate
ventricular chamber size, regional and global wall
motion, left ventricular wall thickness, and valvular
22 The Florida Medicare A Bulletin
October/November 2000