Myocardial Perfusion Imaging and Cardiac Blood Pool Studies (L31072)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L31072

LCD Title
Myocardial Perfusion Imaging and Cardiac Blood Pool Studies

Contractor's Determination Number
CV-017

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region

Original Determination Effective Date
For services performed on or after 11/15/2010

Original Determination Ending Date


Revision Effective Date
For services performed on or after 10/01/2011

Revision Ending Date


CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no Medicare payment shall be made for items or services that €œare not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.€

Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations (CFR), §411.15, exclude routine physical examinations.

Title XVIII of the Social Security Act, §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Section 410.32(b) of the Code of Federal Regulations, as adopted in the Medicare physician fee schedule final rule of October 31, 1997, requires that diagnostic tests covered under §1861(s)(3) of the Social Security Act and payable under the physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a "physician"(§1861(r) of the Social Security Act) to be considered reasonable and necessary and, therefore, covered under Medicare.

§4317(b), of the Balanced Budget Act (BBA), specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.

42 Code of Federal Regulations (CFR) §410.32 and §410.33, indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.

CMS Publication 100-04, Medicare Claims Processing Manual Chapter 4
-200.8 - Billing for Nuclear Medicine Procedures

CMS Publication 100-04, Medicare Claims Processing Manual Chapter 12
-20.4.4 - Supplies

CMS Publication 100-04, Medicare Claims Processing Manual Chapter 13
-20 - Payment Conditions for Radiology Services
-50 - Nuclear Medicine

CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 15
-60 - Services and Supplies
-60.1 - Incident To Physician's Professional Services
-80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
-80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests
Indications and Limitations of Coverage and/or Medical Necessity
Cardiovascular nuclear imaging employs noninvasive techniques to assess alterations in coronary artery flow, as well as ventricular function.

Myocardial perfusion imaging requires intravenous injection of a radioactive agent (radiopharmaceutical/radionuclide).

Often, a second injection is done so that images may be obtained both after stress and at rest.

Diagnostic information obtained includes assessment of blood flow to the myocardium, differentiation of ischemic from infarcted tissue, and identification of reversible and nonreversible defects.

Ventricular function studies may be performed using technetium-based perfusion imaging agents and gated technology and are used to outline the borders of the left ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium.

Patient selection should be based on clinical findings.

Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question.

Patients with a low pretest probability of disease are not usually studied unless a prior exercise stress test demonstrated a presumed false-positive or non-diagnostic result. Selection of the test should be made within the context of other testing modalities to prevent redundancy.

Indications:

The following specific indications may be considered reasonable and necessary and therefore may justify the test:
The patient has an abnormal ECG with a high likelihood of coronary artery disease (CAD) based on multiple risk factors or strongly suggestive symptoms.

The patient takes medication that would make interpretation of a standard exercise test inaccurate.

The patient had an abnormal standard stress test and further evaluation is medically necessary.

The patient has a condition which would likely result in a nondiagnostic or inaccurate standard stress test.

Myocardial perfusion imaging is being done to determine the significance or the extent of myocardial ischemia (or scar), or to assess myocardial viability (e.g., risk stratification following acute myocardial infarction).

The patient has undergone cardiovascular reperfusion: e.g., coronary artery bypass graft, (CABG), percutaneous transluminal coronary angioplasty (PTCA), or thrombolysis, and perfusion imaging is being done to evaluate the effectiveness of the intervention when the patient is symptomatic.

Functional capacity is being assessed when adequate information is not available from the clinical assessment.

The patient has a ventricular wall motion abnormality demonstrated by another imaging modality, and perfusion imaging is needed to further evaluate the abnormality.

The study is used to aid in diagnosis of hypertrophic or dilated cardiomyopathy, or to differentiate ischemic from nonischemic cardiomyopathy.

The study is being done to evaluate a patient receiving chemotherapeutic drugs which are potentially cardio toxic (e.g. doxorubicin).

The study is performed as risk assessment of an intermediate-risk CAD patient prior to high-risk surgery.

A patient with known CAD has a new onset of or a significant change in, symptoms.

To evaluate patients with previously documented silent ischemia where further therapeutic or clinical management decisions are expected.

To evaluate patients in whom silent ischemia is considered highly probable (i.e. a diabetic patient with neuropathic interference with normal sensation of pain).

Post heart transplant for assessment of coronary arteriopathy; or
Evaluation for ventricular dysfunction with post-transplant rejection.

In selected patients, imaging is appropriate in the assessment of patients presenting with chest pain to the Emergency Department;

Unstable coronary syndromes such as angina following acute myocardial infarction typically go directly to coronary angiography. However, a patient with a previous diagnosis of intermediate coronary syndrome, (unstable angina) who is €œmedically stable,€ may be a candidate for nuclear imaging, typically to ascertain whether or not angiography is warranted.

There are currently three main radionuclides used during myocardial perfusion imaging and labeled red blood cells for cardiac blood pool studies.

A9500- Technetium Tc-99m sestamibi, diagnostic, per study dose.

A9502- Technetium Tc 99m tetrofosmin, diagnostic, per study dose.

A9505-TL-201 Thallous chloride, diagnostic, per millicurie, typically an initial dose of 2-4 mCi is given at peak exercise, and imaging is performed immediately, and then 4-6 hours later after redistribution.

A9560-Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries.

Technetium radiopharmaceuticals clear more slowly, allowing imaging up to 4-6 hours post-injection. In a typical one-day protocol, a first dose of 5-8 mCi is given at peak exercise, and a second dose of 15-24 mCi is given at rest, approximately four hours later. In a typical two-day rest/stress protocol, a 24 to 30 mCi dose is given each day.

When medically necessary, cardiovascular stress testing can be performed in conjunction with nuclear medicine procedures. To review related policies, please refer to the LCD titled Cardiovascular Stress Testing.

Limitations:

Cardiovascular Nuclear Imaging would not be considered medically necessary or reasonable:

When incremental information obtained by testing has little or no clinical relevance.

When there is no probability of intervention or change in medical management (e.g., the risk is too high, the patient refuses, or unacceptable comorbidities are present).

When there is repetitive, frequent testing in the absence of changing clinical parameters, especially in individuals with known, stable CAD.

When secondary conditions will potentially decrease both the sensitivity and specificity of testing (e.g., postoperative state, anemia, or poor functional capacity).

When testing is due to first-degree atrioventricular block in an asymptomatic patient with a low-or intermediate-risk profile.

All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified nonphysician (i.e., a nurse practitioner or physician's assistant).

Cardiovascular nuclear tests must be performed under the general supervision of a physician.

Cardiovascular stress testing must be performed under direct physician supervision.

Studies performed for the following indications are not considered reasonable and necessary and therefore will not be paid by Medicare:

Screening for coronary disease, the presence of risk factors alone is not a Medicare-covered indication.

Stimulus to motivate changes in lifestyle (e.g., weight loss or exercise programs do not meet the Medicare medical necessity criteria).

Routine follow-up tests for MI, CABG, or PTCA in the absence of symptoms or clinical indications are not covered (e.g., annual testing in the absence of individualized clinical indications).

Occupational fitness evaluation.


Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.


Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.


034X Nuclear Medicine - General Classification
0482 Cardiology - Stress Test
0636 Pharmacy - Drugs Requiring Detailed Coding
0960 Professional Fees - General Classification
0969 Professional Fees - Other Professional Fee
0974 Professional Fees - Radiology Nuclear
0982 Professional Fees - Outpatient Services

CPT/HCPCS Codes

78451MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC)
78452MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION
78453MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC)
78454MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION
78466MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR QUANTITATIVE
78468MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS TECHNIQUE
78469MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION
78472CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; PLANAR, SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT ADDITIONAL QUANTITATIVE PROCESSING
78473CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, AT REST AND STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT ADDITIONAL QUANTIFICATION
78481CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION
78483CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION
78494CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTITATIVE PROCESSING
78496CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, AT REST, WITH RIGHT VENTRICULAR EJECTION FRACTION BY FIRST PASS TECHNIQUE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
A9500TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE
A9502TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE
A9505THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE
A9512TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE
A9539TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES
A9560TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES
C9898RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY

ICD-9 Codes that Support Medical Necessity

Note: ICD-9 codes must be coded to the highest level of specificity.

Diagnosis codes do not apply to A9512 - A9560, C9898.
249.00 - 249.91SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED - SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED
250.60 - 250.63DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
250.90 - 250.93DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED
394.0 - 394.9MITRAL STENOSIS - OTHER AND UNSPECIFIED MITRAL VALVE DISEASES
395.0 - 395.2RHEUMATIC AORTIC STENOSIS - RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY
396.0 - 396.3MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY
396.8MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES
410.00ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED
410.01ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE
410.02 - 410.82ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE
410.90 - 410.92ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
411.0POSTMYOCARDIAL INFARCTION SYNDROME
411.1INTERMEDIATE CORONARY SYNDROME
411.81ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION
411.89OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER
412OLD MYOCARDIAL INFARCTION
413.0 - 413.9ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS
414.00 - 414.07CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART
414.10 - 414.19ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART
414.2CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY
414.3CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE
414.4CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION
414.8OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
414.9CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED
416.9CHRONIC PULMONARY HEART DISEASE UNSPECIFIED
424.0 - 424.3MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS
425.0 - 425.9ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED
426.10 - 426.9ATRIOVENTRICULAR BLOCK UNSPECIFIED - CONDUCTION DISORDER UNSPECIFIED
427.0 - 427.89PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS
428.0 - 428.9CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
429.0MYOCARDITIS UNSPECIFIED
429.1MYOCARDIAL DEGENERATION
429.2CARDIOVASCULAR DISEASE UNSPECIFIED
429.3CARDIOMEGALY
429.4FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY
429.83TAKOTSUBO SYNDROME
429.89OTHER ILL-DEFINED HEART DISEASES
433.10OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION
433.11OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION
440.20 - 440.9ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS
441.00 - 441.9DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE
745.2 - 745.5TETRALOGY OF FALLOT - OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT
746.00 - 746.7CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - HYPOPLASTIC LEFT HEART SYNDROME
746.81SUBAORTIC STENOSIS CONGENITAL
746.85CORONARY ARTERY ANOMALY CONGENITAL
780.2SYNCOPE AND COLLAPSE
785.1PALPITATIONS
786.02ORTHOPNEA
786.05SHORTNESS OF BREATH
786.09RESPIRATORY ABNORMALITY OTHER
786.50UNSPECIFIED CHEST PAIN
786.51PRECORDIAL PAIN
786.59OTHER CHEST PAIN
794.30UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM
794.31NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)
995.20UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE
996.03MECHANICAL COMPLICATION DUE TO CORONARY BYPASS GRAFT
996.1MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.71OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS
996.72OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT
996.83COMPLICATIONS OF TRANSPLANTED HEART
V15.1PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH
V42.1HEART REPLACED BY TRANSPLANT
V42.2HEART VALVE REPLACED BY TRANSPLANT
V43.3HEART VALVE REPLACED BY OTHER MEANS
V45.81POSTSURGICAL AORTOCORONARY BYPASS STATUS
V45.82PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS
V58.11ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
V58.69LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED
V72.81PRE-OPERATIVE CARDIOVASCULAR EXAMINATION

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements
The condition and treatment is expected to be documented in the medical record and be available upon request.

Medical records must substantiate the medical necessity of the services, including a clinical diagnosis, the specific reason for the study, the reason for use of pharmacologic stress, and must include a formal interpretation and report.

Medical records must contain a copy of the referral order, and the reason for Add-on procedure codes. Code 78496 will be denied if not used in conjunction with code 78472.

Documentation in the patient's medical record must show that physician supervision of testing was in compliance with applicable regulations of the Centers for Medicare & Medicaid Services.

When billing for the purchase of radiopharmaceutical(s), the name, purchase records, dosage administered, and unit price per dose must be on file and available to the contractor upon request.
Appendices
Utilization Guidelines
Rest/stress protocols are reimbursed as one test whether done on the same day or two separate days.
Sources of Information and Basis for Decision
Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201-29.

Baggish AL, Boucher CA, Radiopharmaceutical Agents for Myocardial Perfusion Imaging Circulation 2008;118;1668-1674

Gibbons RJ, Askew JW Hodge D Miller TD Temporal trends in compliance with appropriateness criteria for stress single photon emission computed tomography sestamibi studies in an academic medical center Am Heart J 2010 Mar159(3):484-9.

Other Contractors LCDs
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
J5 MAC
IA, KS, MO, NE, 06/24/2010
Open Meeting 04/22/2010

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction
Start Date of Comment Period
06/24/2010
End Date of Comment Period
08/08/2010
Start Date of Notice Period
10/01/2010
Revision History Number
X
Revision History Explanation
04/19/2010 - In accordance with Section 911 of the Medicare Modernization
Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor  Palmetto.

8/1/2010 - Revenue code 0343 was added to the code range 0340 - 0349
8/1/2010 - Revenue code 0344 was added to the code range 0340 - 0349

8/1/2010 - The description for Revenue code 0340 was changed
8/1/2010 - The description for Revenue code 0341 was changed
8/1/2010 - The description for Revenue code 0342 was changed
8/1/2010 - The description for Revenue code 0349 was changed
8/1/2010 - The description for Revenue code 0482 was changed
8/1/2010 - The description for Revenue code 0636 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - The description for Revenue code 0974 was changed
8/1/2010 - The description for Revenue code 0982 was changed

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).

10/21/2010 corrected statement under Documentation Requirements; Code 78496 will be denied if not used in conjunction with code 78472.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
78451 descriptor was changed in Group 1
78452 descriptor was changed in Group 1
78453 descriptor was changed in Group 1
78454 descriptor was changed in Group 1
78472 descriptor was changed in Group 1
78473 descriptor was changed in Group 1
78481 descriptor was changed in Group 1
78483 descriptor was changed in Group 1
78494 descriptor was changed in Group 1

02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

10/01/2011 ICD-9 annual code updates added code 414.4, codes 425.11 and 425.18 added to range effective 10/01/2011.
Reason for Change
Related Documents
This LCD has no Related Documents.

LCD Attachments

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Page Last Updated: Thursday, 20-Oct-2011 15:31:19 CDT