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RetiredBlue Cross Blue Shield - KansasPolicy N/A

Positron Emission Tomography (PET) Scanning: Cardiac Applications

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Coverage policy for PET cardiac applications (myocardial perfusion, viability, cardiac sarcoidosis, and myocardial blood flow quantification) for Blue Cross and Blue Shield of Kansas members.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyPositron Emission Tomography (PET) Scanning: Cardiac Applications

Policy CodePolicy N/A

Change TypeRetirementadded clarification on investigational use and explicit 'not medically necessary' bucket

Effective DateOctober 28, 2022

Last ReviewOct 22, 2024

Next Review DateN/A

Key ActionVerify member benefits with BCBSKS Customer Service or Provider Network Solutions for coverage and prior authorization given the policy retirement.

SourceLink

POLICY UPDATE CHANGES

This medical policy was retired and is not currently active as of July 1, 2025.

Section E: All other indications for Cardiac PET scanning are considered not medically necessary.

Cardiac PET scanning is experimental/investigational for quantification of myocardial blood flow for cardiac event risk stratification in individuals diagnosed with coronary artery disease.

Jul 1, 2025retired

1997original eff.

Oct 22, 2024last review

Jul 30, 2024evidence update

≥2MFR threshold

1 RCT + follow-upkey trial(s)

Coverage Criteria and Rationale

Medically Necessary Indications

Covered when specified criteria are met

A: Indeterminate SPECT or expected suboptimal SPECT: Cardiac PET may be considered medically necessary to assess myocardial perfusion and diagnose coronary artery disease in individuals with an indeterminate single-photon emission computed tomography (SPECT) scan, or in individuals for whom SPECT could be reasonably expected to be suboptimal in quality on the basis of body habitus (eg, moderate-to-severe obesity).indeterminate SPECT OR expected suboptimal SPECT

Policy item A; body-habitus limitations of SPECT described in Background (chunk 12).

B: Myocardial viability in severe LV dysfunction: Cardiac PET may be considered medically necessary to assess myocardial viability in individuals with severe left ventricular dysfunction to determine candidacy for revascularization.severe left ventricular dysfunction under consideration for revascularization

Policy item B; clinical context for viability assessment (chunk 13).

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyPositron Emission Tomography (PET) Scanning: Cardiac Applications

Policy CodePolicy N/A

Change TypeRetirementadded clarification on investigational use and explicit 'not medically necessary' bucket

Effective DateOctober 28, 2022

Last ReviewOct 22, 2024

Next Review DateN/A

Key ActionVerify member benefits with BCBSKS Customer Service or Provider Network Solutions for coverage and prior authorization given the policy retirement.

SourceLink

On This Page

C: Cardiac sarcoidosis when MRI not possible: Cardiac PET may be considered medically necessary for diagnosing cardiac sarcoidosis in individuals who are unable to undergo magnetic resonance imaging (for example, patients with pacemakers, automatic implanted cardioverter defibrillators, or other metal implants).unable to undergo MRI

Policy item C; MRI contraindication examples provided (chunk 18).

Experimental / Investigational

Experimental / Investigational: Cardiac PET scanning is experimental/investigational for quantification of myocardial blood flow for cardiac event risk stratification in individuals diagnosed with coronary artery disease.myocardial blood flow quantification for risk stratification

Policy item D explicitly states this use is experimental/investigational (chunk 18).

Not Medically Necessary

Other indications - Not medically necessary: All other indications for Cardiac positron emission tomography (PET) scanning are considered not medically necessary.other/unlisted indications

Policy item E explicitly places all other uses in not medically necessary category (chunk 18).

Medically Necessary

Covered when ANY of the following are met

Assess myocardial perfusion after indeterminate SPECT: Cardiac PET may be considered medically necessary to assess myocardial perfusion and diagnose coronary artery disease in individuals with an indeterminate SPECT scan or when SPECT is expected to be suboptimal in quality due to body habitus.indeterminate SPECT OR expected suboptimal SPECT

Policy item A and Background noting body-habitus limitations (chunk 12).

Assess myocardial viability in severe LV dysfunction: Cardiac PET may be considered medically necessary to assess myocardial viability in individuals with severe left ventricular dysfunction as a technique to determine candidacy for revascularization.severe left ventricular dysfunction

Policy item B and clinical context for viability assessment (chunk 13).

Diagnose cardiac sarcoidosis when MRI not possible: Cardiac PET may be considered medically necessary for diagnosing cardiac sarcoidosis in individuals who are unable to undergo magnetic resonance imaging (eg, pacemaker, AICD, or other metal implants).unable to undergo MRI

Policy item C and section summary supporting PET when MRI contraindicated (chunk 87).

Investigational / Not Medically Necessary

Other uses

Quantification of myocardial blood flow for risk stratification: Cardiac PET scanning for quantification of myocardial blood flow (MBF) to guide cardiac event risk stratification in individuals with coronary artery disease is considered investigational/ not medically necessary.MBF/MFR for event risk stratification

Policy item D states this use is experimental/investigational (chunk 18).

All other indications for Cardiac PET scanning are considered not medically necessary.other/unlisted indications

Policy item E explicitly excludes other indications (chunk 18).

Myocardial viability (severe LV dysfunction) — coverage rationale

Covered when PET results meaningfully inform revascularization decisions and management:

Viability assessment to guide revascularization: Patients with severe left ventricular dysfunction who are being evaluated for revascularization where PET identifies sufficient viable myocardium to support a recommendation for revascularization or revascularization workup.sufficient viable myocardium (study-specific thresholds)

Large randomized trial (Positron Emission Tomography and Recovery Following Revascularization) showed benefit in subgroup of patients who received recommended revascularization; nonrandomized studies (Srivatsava et al.) support PET utility (chunks 48-51,50).

Quantitative MBF/MFR (CAD) — coverage rationale

Covered when quantification of MBF/MFR is needed for cardiac event risk stratification in CAD patients:

Quantitative MBF/MFR measurement: Individuals with known coronary artery disease in whom quantitative measurement of myocardial blood flow (MBF) or myocardial flow reserve (MFR) will be used to inform risk stratification or further diagnostic testing.MFR generally: ≥2 considered normal; lower values may prompt invasive testing

Descriptive rationale: MFR definition and thresholds (chunk 54); comparators include coronary angiography with FFR (chunk 55).

Coverage rationale / evidence conclusions

Summary of findings and stance regarding clinical utility and developmental status

Evidence summary: Meta-analyses and cohort studies demonstrate that impaired MFR/MBF measured by PET is associated with increased risk of adverse cardiovascular outcomes; some cohorts suggest identification of low MFR may help select patients who could benefit from early revascularization, but heterogeneity in methods, tracers, and thresholds limits certainty.

See systematic reviews and cohort summaries (chunks 60,62,63,59,71).

Limitations: Diagnostic accuracy relative to FFR is established mainly for 15O-water PET (not available in US); most US studies use 82Rb which has less favorable flow-extraction properties; lack of randomized trials proving MBF/MFR-guided management improves clinical outcomes—methods are developmental and require larger prospective trials.

Limitations and need for further trials summarized (chunks 59,71,60,62).

Indications / Preferred use

Clinical stance summarized from evidence and clinical input

Use of PET when MRI is contraindicated: Magnetic resonance imaging (MRI) is generally recommended first-line for suspected cardiac sarcoidosis, but PET may be utilized for diagnosis in patients unable to undergo MRI (eg, pacemaker, ICD, other metal implants).unable to undergo MRI

Section summary and clinical input support PET utility in MRI-contraindicated patients (chunks 87,89).

Society guideline-based indications and appropriateness

Professional society recommendations and appropriateness criteria summarized in the document include:

ACC/AHA Appropriate Use Criteria and guidelines endorse radionuclide imaging (PET/SPECT) for diagnosis and risk assessment in intermediate- and high-risk CAD and note PET-derived MBF adds diagnostic and prognostic information after ACS is ruled out; PET preferred over SPECT for greater diagnostic accuracy in some guidelines.intermediate-to-high pretest probability

ACC/AHA guideline summaries and 2021/2023 guidance (chunks 91,92).

ACR Appropriateness Criteria consider PET and SPECT appropriate for high-probability CAD evaluation and note PET advantages over SPECT and PET/CT fusion with CCTA can improve accuracy; ACR does not recommend PET for acute nonspecific chest pain with low probability of CAD or for asymptomatic screening.not for low pretest probability or asymptomatic screening

ACR statements (chunk 93).

ASNC/SNMMI - MBF: ASNC/SNMMI guidance notes quantitative MBF/MFR are helpful in specific scenarios (suspected ischemia without obstructive CAD, known CAD for physiologic assessment, multivessel disease suspicion, transplant vasculopathy) but methods require further standardization and outcome data.

ASNC/SNMMI position and joint documents (chunks 95-97).

Cardiac sarcoidosis guidance: AHA, ASNC, SNMMI and related societies endorse FDG-PET for evaluation and management of cardiac sarcoidosis, often alongside CMR; PET appropriate when MRI is inconclusive or not possible and for baseline and therapy reevaluation assessments.

Society guidance on sarcoidosis and PET use (chunks 94,97,101,102).

Policy status and limitations

Policy determinations and notable statements (as summarized from revision history and policy text in this section of the document):

Retired policy status: This medical policy for Cardiac PET scanning has been retired and is not active as of July 1, 2025; contact Blue Cross and Blue Shield of Kansas Customer Service or Provider Network Solutions for current coverage determinations.policy retired 2025-07-01

Retirement and revision history entries (chunks 111,112,39).

Not medically necessary bucket: Section E states that all other indications for Cardiac PET scanning that are not described as medically necessary are considered not medically necessary.other/unlisted indications

Section E addition in coding/revision notes (chunk 112).

Experimental/Investigational statement: The policy clarifies that cardiac PET scanning is experimental/investigational for quantification of myocardial blood flow for cardiac event risk stratification in individuals diagnosed with coronary artery disease.MBF/MFR for risk stratification

Revision entry and policy text (chunk 112, chunk 18).

All indications for Cardiac positron emission tomography (PET) scanning that are not specifically listed as A through C in the policy are considered not medically necessary. See Section E for the policy-level exclusion stating that services outside the enumerated medically necessary indications may be denied and that member contract benefits should be consulted for coverage determinations.

Consistent with the policy exclusions, all other indications for Cardiac PET scanning are considered not medically necessary. Claims for uses not listed among the medically necessary items A–C may be denied and providers should verify member contract benefits prior to service.

This medical policy has been retired and is not currently active as of July 1, 2025. For questions about current coverage or to determine whether an exclusion remains active, contact Blue Cross and Blue Shield of Kansas Customer Service or your Provider Network Solutions representative.

Findings from studies that used 15O-water PET cannot be extrapolated to clinical settings where 82Rb chloride is used because 15O-water PET (with more favorable flow-extraction characteristics) is not available in the United States and tracers differ in flow quantification performance.

The document is marked as retired effective July 1, 2025. Because the policy is retired, explicit active coverage exclusions are not provided in this text; for current coverage determinations or active exclusions contact Blue Cross and Blue Shield of Kansas Customer Service or Provider Network Solutions.

Clinical guidance summarized in the policy and referenced society guidance indicate that PET is not recommended for evaluation of patients with acute nonspecific chest pain who have a low pretest probability of coronary artery disease, and is not recommended for routine screening of asymptomatic patients. Use of PET should be reserved for appropriate clinical indications (for example, indeterminate SPECT, poor-quality SPECT, myocardial viability assessment, or cardiac sarcoidosis when MRI is contraindicated) and justified by documentation of the covered indication.

Reiterating the policy exclusion: All indications not listed as A–C are considered not medically necessary. Providers should expect that services for unlisted indications may be denied and should verify benefit coverage before ordering.

Cardiac PET is covered only for the specific medically necessary indications enumerated in items A–C of the policy. Cardiac PET for any indication other than those listed as medically necessary is considered not medically necessary. Additionally, quantification of myocardial blood flow for cardiac event risk stratification is labeled investigational in the policy.

Cardiac PET applications beyond the listed medically necessary indications are considered not medically necessary in this policy. The policy also states that quantification of myocardial blood flow (MBF) or myocardial flow reserve (MFR) for cardiac event risk stratification is experimental/investigational, noting limited direct evidence from randomized trials demonstrating clinical outcome benefits from MFR-guided management.

The provided document excerpt does not include additional explicit 'not medically necessary' statements beyond the Section E language and the investigational designation for MBF/MFR; however, the policy retirement notice means active coverage language is not present in this retired text and providers should contact the payer for current operational rules.

No randomized controlled trials were identified that demonstrate improved clinical outcomes from management guided by PET-derived myocardial flow reserve (MFR). The policy notes the absence of RCT evidence comparing patient outcomes managed with MBF/MFR-guided strategies versus without PET, and indicates that larger prospective trials are needed to establish clinical utility.

The policy did not identify studies that directly evaluate clinical utility (i.e., impact on patient health outcomes) of PET for certain indications such as cardiac sarcoidosis or MBF/MFR-guided management. Where direct outcome studies were lacking, conclusions rely on clinical validity, cohort studies, and guideline statements rather than definitive randomized evidence.

The policy highlights that reporting absolute hyperemic blood flow or flow reserve may be ambiguous or misleading in certain clinical situations—examples include patients post-coronary artery bypass grafting, those with large transmural infarcts, advanced renal dysfunction, or severe left ventricular dysfunction—where MBF/MFR interpretation can be confounded.

The policy explicitly states that MBF/MFR quantification for cardiac event risk stratification is experimental/investigational. As such, cardiac PET used solely for quantification of myocardial blood flow to stratify cardiac event risk is considered investigational and not covered under this policy.

Covered Indications (Specific Uses)

Myocardial perfusion imaging to diagnose CAD

Myocardial perfusion imaging to diagnose CAD: Indicated when SPECT is indeterminate OR SPECT likely to be suboptimal due to body habitus (eg, moderate-to-severe obesity); PET used to assess myocardial perfusion and diagnose coronary artery disease.indeterminate SPECT OR expected suboptimal SPECT

Imaging indication A and Background discussion (chunks 18,12).

Myocardial viability assessment

Myocardial viability assessment: Indicated for assessment of myocardial viability in severe left ventricular dysfunction to guide revascularization decisions; PET may identify viable myocardium and inform revascularization vs medical management.severe LV dysfunction

Imaging indication B and supporting randomized and nonrandomized evidence (chunks 18,13,48,50,51).

Cardiac sarcoidosis evaluation

Cardiac sarcoidosis evaluation: Indicated for diagnosis of cardiac sarcoidosis in individuals unable to undergo MRI; PET detects inflammatory lesions and can be used alongside clinical evaluation and other imaging modalities.unable to undergo MRI

Imaging indication C and clinical context for sarcoidosis detection (chunks 18,73,87).

Appropriate clinical indications for cardiac PET

Indeterminate SPECT or expected poor SPECT quality: Use PET to assess myocardial perfusion when SPECT is indeterminate or likely suboptimal due to body habitus.

Appropriate clinical indication A (chunks 18,12).

Severe LV dysfunction for viability assessment: Use PET to assess myocardial viability in severe LV dysfunction to determine candidacy for revascularization.

Appropriate clinical indication B (chunks 18,13,48).

Cardiac sarcoidosis when MRI contraindicated: Use PET for diagnosing cardiac sarcoidosis in patients unable to undergo MRI (eg, pacemaker/AICD or other metal implants).

Appropriate clinical indication C (chunks 18,87).

Myocardial viability assessment prior to revascularization

Viability assessment prior to revascularization: Severe left ventricular dysfunction in patients who are potential candidates for revascularization; PET used to determine myocardial viability (FDG perfusion mismatch identifies hibernating viable myocardium).none specified

Clinical context and population for viability assessment (chunks 37,38) and relation to perfusion/metabolic imaging (chunk 54).

Quantitative perfusion (MBF/MFR) for risk stratification in CAD

Quantitative perfusion (MBF/MFR) for risk stratification in CAD: Individuals with known coronary artery disease for whom quantifying MBF or MFR will be used for cardiac event risk stratification; MFR generally ≥2 is considered normal and lower values may prompt further invasive testing.MFR ≥2 considered normal

Clinical context, population, and intervention description with MFR threshold (chunks 52-54).

Quantification of MBF/MFR and PET for suspected cardiac sarcoidosis

Quantification of MBF/MFR and PET for suspected cardiac sarcoidosis: Quantitative PET MBF/MFR measurement may be used in risk stratification contexts and FDG-PET used to detect inflammatory lesions in suspected cardiac sarcoidosis; PET can support diagnosis when MRI not possible.

Document discusses prognostic associations for MBF/MFR and diagnostic intent for sarcoidosis (chunks 73,54).

Suspected cardiac sarcoidosis when MRI is not possible

Suspected cardiac sarcoidosis when MRI is not possible: Use PET for patients with suspected cardiac sarcoidosis who cannot undergo cardiac MRI; PET can detect inflammatory lesions and support diagnosis and management along with clinical data.unable to undergo MRI

Section summary and clinical input support PET when MRI contraindicated (chunks 87,89).

Appropriate clinical indications summarized from professional society guidance

Professional society recommendations and appropriateness criteria summarized from referenced guidance:

Intermediate-to-high pretest likelihood of CAD: Rest-stress PET myocardial perfusion imaging is appropriate for patients with intermediate-to-high pretest likelihood of coronary artery disease; PET preferred for greater diagnostic accuracy in some guidelines.intermediate-to-high pretest probability

ACC/ACHA and SNMMI/consensus recommendations (chunks 91,92,101).

Use in coronary microvascular dysfunction: SNMMI expert panel recommends PET imaging to detect coronary microvascular dysfunction in patients with chest pain but no obstructive CAD.

SNMMI consensus (chunk 101).

PET for sarcoidosis assessment and therapy monitoring: Expert society guidance supports FDG-PET for evaluation and monitoring of cardiac sarcoidosis, often integrated with CMR and clinical data.

ASNC/SNMMI and joint guidance references (chunks 95,97,102).

Cardiac sarcoidosis / myocardial viability and perfusion imaging (historical indications referenced)

Diagnosing cardiac sarcoidosis (historical): Cardiac PET scanning has historically been included as a method to diagnose cardiac sarcoidosis in policy and references, but the overall medical policy text has been retired; clinicians should refer to society guidance and contact payer for current coverage.

Historical references and revision notes cite sarcoidosis indications and related literature (chunks 111,123).

Not Covered / Investigational Services

Cardiac PET for quantification of myocardial blood flow to inform cardiac event risk stratification is designated not covered / experimental or investigational in this policy. The policy also reiterates that indications outside the listed medically necessary criteria (A–C) are considered not medically necessary.

The policy lists quantification of myocardial blood flow for cardiac event risk stratification as experimental/investigational and states that all other non-listed indications are considered not medically necessary. This exclusion is tied to limited direct evidence demonstrating that MBF/MFR-guided strategies improve clinical outcomes.

The policy has been marked retired as of July 1, 2025. Because it is retired, the document does not contain active coverage language in this excerpt; providers should contact Blue Cross and Blue Shield of Kansas for current coverage guidance.

The policy reiterates that PET for myocardial blood flow quantification is considered investigational/not covered for cardiac event risk stratification. This statement is repeated in the document as part of the investigational/ not-covered determinations.

The document repeatedly emphasizes the investigational status of PET-derived MBF quantification for risk stratification: the policy characterizes this application as experimental and not covered pending stronger prospective outcome data.

The policy notes the absence of randomized controlled trials comparing MFR-guided management to usual care; this lack of direct trial evidence underlies the designation of MBF/MFR quantification for risk stratification as investigational and not covered.

The policy repeats that PET quantification of myocardial blood flow for cardiac event risk stratification remains investigational due to limitations in evidence, tracer generalizability, and lack of randomized outcome data.

Procedure and Radiopharmaceutical Codes

No explicit CPT/HCPCS/ICD codes in these chunksmixed

No codes listed

Coding list (procedure and radiopharmaceutical codes)CPT | HCPCS

78429	Myocardial imaging, PET, metabolic evaluation study; single study; with concurrently acquired CT transmission scan.
78430	Myocardial imaging, PET, perfusion study; single study, at rest or stress, with concurrently acquired CT transmission scan.
78431	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress, with concurrently acquired CT transmission scan.
78432	Myocardial imaging, PET, combined perfusion with metabolic evaluation study; dual radiotracer (e.g., myocardial viability).
78433	Myocardial imaging, PET, combined perfusion with metabolic evaluation study; dual radiotracer; with concurrently acquired CT transmission scan.
78434	Absolute quantitation of myocardial blood flow (AQMBF), PET, rest and pharmacologic stress (List separately).
78459	Myocardial imaging, PET, metabolic evaluation study.
78491	Myocardial imaging, PET, perfusion study; single study, at rest or stress.
78492	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress.
A9526	Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries.

1–10 of 13

1/2

Listed CPT/HCPCS Codesmixed

78491	Myocardial imaging, positron emission tomography (PET), perfusion study; single study, at rest or stress
78492	Myocardial imaging, positron emission tomography (PET), perfusion study; multiple studies at rest and stress
A9526	Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries
A9552	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
A9555	Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries
A9598	Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified

Removed historical codesmixed

0482T	Previously listed CPT (removed later)
G0235	Previously listed HCPCS (removed later)

inv-30: Intermediate pretest probability for CAD — typical ranges (10%–90% / 25%–75%)

Intermediate pretest probability — common clinical rangesGenerally defined as intermediate risk for CAD; document cites ranges of 25%–75% and 10%–90% pretest probability

Guideline-based definitionACC guidance referenced: intermediate risk often considered 10%–90% disease probability

Clinical applicationUse PET myocardial perfusion imaging for patients in the intermediate pretest probability group when noninvasive testing is indicated

inv-31: Myocardial flow reserve (MFR) — MFR ≥2 considered normal

Normal MFR thresholdMFR ≥2 is generally indicative of normal perfusion

DefinitionMFR defined as stress MBF divided by rest MBF

Clinical implicationLower MFR values may prompt further invasive testing to rule out epicardial CAD

inv-32: Viable myocardium threshold for revascularization (study-specific) — >7% myocardium used in Srivatsava et al

Study-specific viable myocardium thresholdIn Srivatsava et al., patients with >7% viable myocardium underwent revascularization

Study population120 patients with left ventricular dysfunction who underwent SPECT-CT and FDG-PET/CT

Outcome used to guide treatmentThreshold (>7% viable myocardium) determined whether patients received surgical revascularization vs medical management

inv-33: MFR classification thresholds used in cohorts — Low <1.8, Intermediate 1.8–2.0, Normal ≥2.0; CFCsevere thresholds

MFR classification — cohort thresholdsLow: <1.8; Intermediate: 1.8–2.0; Normal: ≥2.0 (as used in Patel et al.)

CFCsevere regional thresholdsCFCsevere defined by pixels with MFR ≤1.27 and stress perfusion ≤0.83 (Gould et al. cohort)

Clinical associationsLower MFR categories associated with higher mortality; revascularization benefit observed in some low-MFR/CFCsevere groups

Provider Actions, Documentation, and Contact

Prior Authorization

Prior Authorization / Benefit Verification

Verify member contract and benefits prior to ordering services. Member contract language and state/federal mandates take precedence over this policy. Contact Blue Cross and Blue Shield of Kansas Customer Service or your Provider Network Solutions representative to confirm eligibility and any plan-specific requirements.

Verify member benefits and contract language at the time of service
Contact BCBSKS Customer Service for benefit verification

Prior Authorization

Prior Authorization and Coverage Confirmation

Prior authorization or coverage confirmation may be required depending on the member's contract. Justify cardiac PET by documenting that the indication meets a listed medically necessary use (Policy items A–C) or document why SPECT would be suboptimal or indeterminate. For coverage questions or to request authorization, contact Blue Cross and Blue Shield of Kansas Customer Service or your Provider Network Solutions representative.

Document clinical indication consistent with Policy A–C
If indication is outside Policy A–C, expect denial (see 'Not medically necessary')
Contact BCBSKS Customer Service for prior authorization/coverage confirmation

Note

Prior Authorization — None Specified Here

No specific prior authorization requirements are stated within these policy chunks. Providers should still verify member benefits and any payer-specific prior authorization rules before scheduling the service.

Policy text does not specify a universal prior authorization rule
Check the member's contract and payer portal for site-specific prior auth rules

Note

Prior Authorization Not Stated Here

The policy text does not explicitly state prior authorization rules for every scenario. When prior authorization is not described, rely on the member's contract and contact BCBSKS Customer Service for direction.

If prior authorization guidance is absent, confirm via Customer Service or provider portal

Prior Authorization

Prior Authorization / Coverage Inquiries

This policy was retired effective July 1, 2025. For any coverage inquiries or to determine current authorization requirements, contact Blue Cross and Blue Shield of Kansas Customer Service or your Provider Network Solutions representative.

Policy retired: July 1, 2025
For coverage questions, contact BCBSKS Customer Service

Denial Risk

Coverage Limits and Denial Risk

Cardiac PET performed for indications other than the medically necessary uses listed in Policy A–C may be denied. Verify benefits and document clinical justification to reduce denial risk.

Section E: All other indications are considered not medically necessary and may be denied
Confirm member contract benefits prior to service to avoid unexpected denials

Note

None Specified in These Chunks

No additional provider actions are specified in the provided chunks beyond benefit verification, documenting clinical indications, and contacting BCBSKS for coverage questions.

Follow standard provider workflows: verify benefits, document clinical justification, obtain authorizations if required

Denial Risk

Not Medically Necessary Indications

Indications not explicitly listed as medically necessary in Policy A–C (for example, myocardial blood flow quantification for cardiac event risk stratification) are considered not medically necessary or experimental/investigational per Policy D and E. Claims outside the criteria may be denied.

Policy D: MBF quantification for cardiac event risk stratification is experimental/investigational
Policy E: All other indications are not medically necessary

Documentation Required

Required Clinical Indication

Document the required clinical indication in the medical record when ordering cardiac PET. Indications supported in the policy include: indeterminate SPECT or expected suboptimal SPECT due to body habitus (Policy A), assessment of myocardial viability in severe LV dysfunction to determine revascularization candidacy (Policy B), and diagnosis of cardiac sarcoidosis when MRI is not possible (Policy C).

Document why SPECT is indeterminate or why SPECT would likely be suboptimal (e.g., body habitus)
For viability studies, document severe left ventricular dysfunction and intent to assess candidacy for revascularization
For cardiac sarcoidosis, document inability to undergo MRI (e.g., pacemaker, ICD, metal implants)

Documentation Required

Documentation Noted in Study-Selection Criteria

Study-selection criteria and expectations for inclusion in evidence reviews require documentation that studies report on the marketed version of the technology, include a suitable reference standard, and describe patient/sample clinical characteristics and selection criteria. When referencing literature to support use, ensure these elements are described.

Confirm studies reference the marketed technology/version
Reference standards used in studies should be described
Patient/sample clinical characteristics and selection criteria must be documented in studies

Documentation Required

Study Selection Documentation Expectations

When documenting study-selection or local validation information (e.g., for peer review or coverage appeals), include technology version, reference standards, patient selection criteria, and clinical characteristics. Policy reviewers expect these details in studies assessing diagnostic accuracy and clinical utility.

Describe the technology version and any algorithms used
Describe the reference standard used for accuracy measurements
Describe patient inclusion/exclusion criteria and clinical characteristics

Documentation Required

Documentation Expectations

Clinical documentation for cardiac PET orders should include the clinical evaluation, imaging findings (including prior SPECT results if relevant), and the rationale for choosing PET over alternate modalities. For diagnostic accuracy or outcomes reporting, include reference standards used and follow-up data where applicable.

Include prior imaging results (e.g., indeterminate SPECT) and reasons PET is expected to add diagnostic value
Document imaging findings and how results will influence management (e.g., revascularization decisions)
For research or appeals, provide reference standards and follow-up/outcome data

Billing Rule

Coding Informational Note

Billing should include appropriate CPT/HCPCS codes and radiopharmaceutical codes, and the codes listed in the policy are considered medically necessary only if the procedure is performed according to the Policy section. Inclusion of codes in the policy does not guarantee coverage—verify member contract benefits.

Codes are medically necessary ONLY if the procedure meets Policy criteria
Inclusion of codes does not imply coverage—refer to the member's contract benefits
Contact BCBSKS for coding/billing questions

Note

Preferred Imaging Pathway

PET is supported as a preferred alternative pathway for specific scenarios: when SPECT is indeterminate or expected to be suboptimal (e.g., due to body habitus) and when MRI is contraindicated (e.g., pacemaker/ICD or metal implants) for cardiac sarcoidosis evaluation. Document the reason PET is selected.

Use PET when SPECT is indeterminate or likely suboptimal due to body habitus
Use PET for cardiac sarcoidosis diagnosis when MRI cannot be performed (pacemaker, ICD, metal implants)

Definitions and Key Concepts

inv-63: Myocardial flow reserve (MFR) definition and clinical context

MFR definitionMyocardial flow reserve (MFR) = stress MBF / rest MBF (ratio of hyperemic to resting myocardial blood flow)

Normal thresholdMFR ≥2 generally indicates normal perfusion and good prognosis

Clinical contextQuantitative MFR by PET is used to assess myocardial perfusion, stratify risk, and may help identify candidates for revascularization; methods vary by tracer and center

inv-64: Myocardial viability — PET identifies metabolically active (viable) myocardium

Definition — viability by PETPET identifies metabolically active (viable) myocardium using perfusion tracer plus 18F-FDG metabolic imaging

FDG/blood flow mismatchFDG uptake in areas of hypoperfusion suggests hibernating but viable myocardium

Clinical useAssessment typically applied in patients with severe LV dysfunction being considered for revascularization

inv-65: Indeterminate SPECT — definition reference

Definition — indeterminate SPECTIndeterminate SPECT: a SPECT study that does not provide conclusive assessment of myocardial perfusion, prompting further testing such as PET

Common causesIndeterminate or suboptimal SPECT can be due to body habitus (eg, moderate-to-severe obesity) and attenuation artifacts

Policy actionPET may be used when SPECT is indeterminate or expected to be suboptimal

inv-66: Myocardial viability assessment (definition)

Myocardial viability assessment — purposeUse PET to determine whether left ventricular dysfunction is due to viable (hibernating) myocardium versus nonviable scar

TechniquesCommon technique uses N-13 ammonia (perfusion) with 18F-FDG (metabolic) to detect FDG/blood flow mismatch

Clinical decision impactIdentification of viable myocardium can guide revascularization decisions and predict improvement in LVEF after revascularization

inv-67: FDG/blood flow mismatch — definition

Definition — FDG/blood flow mismatchFDG uptake in areas of hypoperfusion on perfusion imaging, indicating viable but hibernating myocardium

MethodologyUses perfusion tracer (eg, N-13 ammonia) for blood flow and 18F-FDG for metabolic activity to detect mismatch

Clinical relevanceMismatch suggests potential benefit from revascularization leading to improved LV function

inv-68: MFR — stress MBF / rest MBF; MFR ≥2 indicates normal perfusion

MFR formulaMFR = stress myocardial blood flow (MBF) / rest MBF

Normal threshold restatedMFR ≥2 indicates normal perfusion and reliably excludes high‑risk angiographic disease when stress MBF >2 mL/min/g and MFR >2

Clinical implicationAs MFR decreases, likelihood of multivessel obstructive CAD increases and prognosis worsens

inv-69: MFR formula and normal threshold restated

MFR formula reiteratedMFR = stress MBF divided by rest MBF (ratio of hyperemic to resting flow)

Normal threshold reiteratedMFR ≥2 generally indicates normal perfusion and favorable prognosis

Measurement units/contextMBF reported in mL/min/g; thresholds and interpretation may vary by tracer and cohort

inv-70: CFC / CFCsevere — coronary flow capacity definition and severe thresholds

Coronary flow capacity (CFC) conceptCFC maps combine CFR/MFR and stress perfusion per pixel to classify regional flow impairment

CFCsevere thresholdsCFCsevere defined by pixels with MFR ≤1.27 and stress perfusion ≤0.83 in cited cohort

Clinical findingsPatients with CFCsevere or global MFR <2 and global stress perfusion <1.8 had lower mortality with revascularization in cohort analyses

inv-71: Cardiac sarcoidosis diagnostic core criteria (ATS) — core diagnostic elements

ATS core diagnostic elementsDiagnostic criteria include: compatible clinical presentation, nonnecrotizing granulomatous inflammation in ≥1 tissue sample, and exclusion of alternative causes

Role of imagingImaging (echocardiogram, cardiac MRI, FDG‑PET) is used alongside clinical data to detect cardiac sarcoidosis

Population contextPET is particularly considered when MRI cannot be performed

inv-72: Population and intervention for cardiac sarcoidosis PET studies

Target populationIndividuals with suspected cardiac sarcoidosis who cannot undergo MRI

InterventionPET scanning (including 18F‑FDG PET/PET‑CT) used to detect inflammatory lesions and assess metabolic activity

Clinical integrationPET findings are interpreted in conjunction with clinical evaluation and other imaging modalities

inv-73: MBF / MFR measurement units and definitions

MBF measurement unitsMBF is reported in mL/min/g of myocardium

MFR definition reiteratedMFR is the ratio of hyperemic (stress) to resting MBF; values and cutpoints (eg, >2) used for risk stratification

Regional thresholdsRegional stress MBF <1.5 mL/min/g and MFR <1.5 may indicate regional flow‑limiting disease

inv-74: Cardiac PET scanning — general descriptor for imaging scope (perfusion, wall motion, EF, metabolism)

Scope of cardiac PET scanningCardiac PET includes assessment of myocardial perfusion, ventricular wall motion and ejection fraction, and metabolic imaging (eg, FDG) for viability or sarcoidosis evaluation

Clinical capabilitiesPET can quantify MBF and MFR and detect inflammatory lesions for sarcoidosis assessment

Comparison to SPECTPET offers greater spatial resolution than SPECT and is preferred when SPECT is indeterminate or expected to be suboptimal

Prior Authorization and Benefit Verification

Prior Authorization

Prior authorization per member contract

Prior authorization and benefit verification for PET should follow the member's contract; contact BCBSKS Customer Service to confirm current authorization requirements.

Prior authorization/benefit verification is determined by member contract.
Contact BCBSKS Customer Service prior to scheduling when uncertain.

Prior Authorization

Obtain coverage confirmation prior to service

Given the policy details and the retirement notice, obtain coverage confirmation or prior authorization from BCBSKS before performing PET.

Document the covered indication in the authorization request.
Confirmation is recommended because the policy is retired and plan rules may differ.

Prior Authorization

Contact payer for prior authorization decisions

Because the policy is retired, contact Blue Cross and Blue Shield of Kansas Customer Service or Provider Network Solutions for current prior authorization and coverage determinations.

Payer representatives handle coverage determinations for retired policies.
Do not rely on this retired policy for active authorization guidance.

Note

No prior authorization thresholds specified here

This excerpt does not specify numerical prior authorization thresholds or automated authorization rules; verify any thresholds with the payer.

No prior authorization thresholds are provided in these chunks.

Prior Authorization

Check payer for current prior authorization rules

Policy retirement requires providers to check with the payer for current prior authorization requirements and processes.

Retired policy — payer may have alternative prior authorization rules or processes in place.

Prior Authorization

Refer to member contract for authorization thresholds

Authorization thresholds are not specified in this excerpt; refer to the member contract or BCBSKS for any authorization criteria or limits.

Refer to member contract and payer guidance for authorization thresholds.

Prior Authorization

Retired policy — contact payer for authorization rules

Because the policy is retired, contact the payer to determine current prior authorization rules and processes.

Provider Network Solutions or Customer Service can advise on current requirements.

Contrast and Related Imaging Rules

Billing Rule

No contrast-specific rules provided here

No contrast-specific requirements are provided in this excerpt of the policy.

The document does not define contrast administration rules for cardiac PET in these sections.

Billing Rule

Include ventricular wall motion/ejection fraction when performed

If ventricular wall motion or ejection fraction imaging is performed as part of myocardial PET perfusion studies, include those services in coding and documentation as noted in the coding section.

Coding examples include imaging of ventricular wall motion(s) and/or ejection fraction when performed as part of PET perfusion studies (see CPT 78491/78492).

Frequency Limits

inv-85: PET — frequency limits placeholder

Frequency limits — policy noteNo specific PET frequency limits provided in the document (frequency limits placeholder)

Policy status — retiredPolicy has been retired as of July 1, 2025; check payer for current frequency/prior‑auth rules

Practical implicationProviders should verify member benefits and prior authorization requirements with BCBSKS at time of service

Background and Evidence Summary

Positron emission tomography (PET) uses positron-emitting tracers with coincidence detection and generally provides greater spatial and temporal resolution than SPECT. Cardiac PET has been evaluated for diagnosing coronary artery disease, assessing myocardial viability in severe left ventricular dysfunction, quantifying myocardial blood flow and flow reserve (MBF/MFR), and detecting inflammatory activity in suspected cardiac sarcoidosis. PET is particularly useful when SPECT is indeterminate or expected to be suboptimal because of body habitus (for example, moderate-to-severe obesity).

Revision History and Policy Changes

2013-10-30revision

Cardiac applications were separated into a standalone Cardiac PET policy, with updates to Description, Rationale, Coding (added ICD-10 diagnosis codes), and References.

2015-10-22revision

Policy language updated (clarified PET/SPECT wording, revised background/guideline references), added Item D labeling MBF quantification as experimental/investigational, and coding changes (removed CPT 78399; added HCPCS A9555).

2017-10-01revision

Coding updates: removed ICD code I50.9 and added multiple ICD codes (I21.9, I21.A1, I21.A9, I50.810–I50.814, I50.82–I50.84, I50.89).

2018-11-26revision

Policy published (effective Nov 26, 2018) with description updates; coding and policy wording refinements including addition of CPT 0482T and HCPCS A9598 and G0235 earlier in the record.

2020-01-01revision

Coding section updated: added CPT codes 78429, 78430, 78431, 78432, 78433, 78434 and revised CPT 78459, 78491, 78492; removed CPT 0482T.

2022-10-28revision

Policy updated: Section D clarified to label quantification of myocardial blood flow for cardiac event risk stratification in individuals with coronary artery disease as experimental/investigational; Section E ('all other indications not medically necessary') was added and coding nomenclature was updated.

2023-10-24revision

Description, Rationale, and Coding sections were updated; ICD-10 codes were removed in coding updates recorded on this date.

2024-10-22review

Latest review and updates to Description, Rationale, and References recorded (policy maintained prior conclusions).

2025-07-01retirementLatest

Medical policy retired and is not currently active as of July 1, 2025; no further reviews or updates will be made; contact BCBSKS Customer Service or Provider Network Solutions for coverage questions.

The policy is explicitly noted as retired. The retirement statement indicates that no further reviews or updates will be made, and that providers should contact Blue Cross and Blue Shield of Kansas Customer Service or Provider Network Solutions for questions about current coverage or prior authorization requirements.

The policy adds an explicit Section E stating that all other indications for Cardiac PET scanning are considered not medically necessary. This creates a clear 'all other' exclusion for any use not listed among the medically necessary items A–C.

Limitations and appropriateness: Society documents note MBF/MFR methods require standardization; PET not appropriate for low pretest probability or routine asymptomatic screening.not for low pretest probability or routine screening

ACR and society position statements (chunks 93,95,97).