Policy applies to Ohio; unproven/limited services reviewed under Ohio rules

This Medical Policy applies only to the state of Ohio. Any requests for services that are stated as unproven or that have coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

CPT code listing does not imply prior authorization

Inclusion of a CPT code in these guidelines does not by itself indicate that the code is subject to management or requires prior authorization; actual prior authorization requirements are determined by payer operations.

Prior authorization may be required for 3D rendering and segmentation

Providers may be required to obtain prior authorization for 3D rendering and related segmentation services even when the base imaging study is not subject to prior authorization.

• Applicable codes include CPT 76376 and 76377 and HCPCS C8001.
• Document physician supervision/participation for 3D reconstruction per guidance when submitting authorization or documentation.

Single-unit rule for guidance codes; limited CT not for treatment planning

Report only one unit of any radiologic guidance code per individual encounter (date of service); CPT 76380 (limited CT) must not be used for treatment planning.

• Examples of guidance codes limited to one unit per encounter: 77012, 77013, 77021, 77022, 76942, 77002–77003.
• CPT 76380 is for limited or follow-up CT and is inappropriate to capture 'extra slices' or to serve as treatment-planning CT.

PET/MRI is allowed only when PET/CT criteria met or PET/CT unavailable

PET/MRI is considered medically necessary only when condition‑specific PET/MRI criteria are met, or when the individual meets PET/CT criteria and PET/CT is unavailable and the provider requests PET/MRI instead.

• When authorized in lieu of PET/CT, report PET/MRI using CPT 78813 (PET whole‑body) plus CPT 76498 (MRI unlisted) as specified.

Prior clinical evaluation and documentation required before advanced cardiac imaging

A pertinent clinical evaluation (history, physical exam, appropriate labs and prior non‑advanced testing) should be available and submitted prior to advanced cardiac imaging except for guideline-supported scheduled surveillance.

• Include recent ECGs, chest x‑ray or prior echocardiography performed after symptom onset or change; obtain most recent prior stress test when relevant.

Prior authorization may be required for stress imaging and AQMBF

Prior authorization may be required, per payer rules, for stress imaging and AQMBF codes; check payer processes for listed CPT and Category III codes.

• Examples include stress echo (93350, 93351), SPECT/PET MPI (78451–78454, 78491–78492, 78491/92), and AQMBF add‑on codes (+78434, 0899T, 0900T).

Allow multiple potential TTE CPT codes on pre-authorization for pediatric cases

For preoperative pediatric transthoracic echocardiography, providers may request multiple potential CPT codes at pre-authorization because the definitive code may depend on findings during the study.

• Common pre-authorization requests include combinations of 93303, 93320, 93325, and 93306 when congenital versus non-congenital findings are uncertain.

Prior authorization expected for repeat TTE outside stated intervals

Prior authorization may be required when repeat TTE is requested outside the medically necessary intervals or when frequency limits are exceeded; requests should reference the specific interval criteria.

• Examples of intervals: every 3 years for certain mild valvular disease, every 2 years for some cardiomyopathy screening, yearly for specified conditions.

Post-procedure surveillance TTE intervals and prior authorization note

Certain post‑procedure surveillance TTEs are specified as medically necessary at defined intervals (for example after transcatheter tricuspid valve replacement: 1 month, 6 months, 1 year, then annually) and may require prior authorization per payer processes.

• Follow the procedure‑specific surveillance schedule when submitting authorization (e.g., CPT 93306 for listed follow‑up intervals).

Follow related policy references for device/LVAD and specialized prior authorization

Prior authorization requirements for specialized device, LVAD, and other programmatic services are not detailed here; follow related policy references and payer prior authorization processes for those services.

TEE indications and prior authorization for procedural follow‑up

TEE is medically necessary for specific indications listed in the guideline (e.g., suspected endocarditis, intracardiac mass, pre‑procedural LAA closure assessment) and follow-up imaging for LAA closure devices (45 days, additional if peri‑device gap ≥5 mm, and 1 year) may require prior authorization per payer process.

• Document indication and timing (e.g., pre‑procedural, 45‑day post‑LAA closure) when requesting authorization.

Prior authorization may be required for CPT 93356 to confirm indication

CPT 93356 (myocardial strain imaging) is medically necessary only in specified situations (initial LVH evaluation with defined criteria, heart transplant evaluation/surveillance, and cardiotoxic therapy monitoring); prior authorization may be required to confirm documentation meets these indications.

• For initial LVH evaluation, document both unclear etiology of LVH not due to hypertensive heart disease and concern for infiltrative cardiomyopathy.
• For cardiotoxic therapy surveillance, document planned/ongoing cardiotoxic therapy and whether the study is baseline or re‑evaluation.

Authorization and coding implications for nuclear cardiac imaging

Prior authorization and correct coding for nuclear cardiac imaging follow payer rules; do not report first‑pass studies or MUGA/SPECT MUGA codes in conjunction with MPI codes, and be aware some techniques are experimental or obsolete which may affect authorization.

• Do not bill 78481/78483, 78472/78473, or 78494 together with MPI CPT codes (e.g., 78451–78454).
• Attenuation correction is included in MPI codes and should not be billed separately.

Review prior imaging and clinical course before additional advanced imaging

Review prior imaging and the individual's clinical course before ordering further advanced imaging; repeat studies generally require documentation of progression, recurrence, or that the outcome will change management.

• Obtain and include results of prior diagnostic tests and prior imaging when requesting authorization to avoid denial for duplicate or unnecessary studies.

Do not use CPT 76380 in lieu of full diagnostic CT or for treatment planning

CPT 76380 (limited CT) should not be used as a substitute for full diagnostic CT codes to capture additional slices or for treatment‑planning purposes.

• Use 76380 only for genuinely limited or follow‑up CT work when a full diagnostic code is not performed.

Obtain prior non‑advanced testing before advanced imaging

Obtain prior non‑advanced testing (ECG, chest x‑ray, echocardiogram) and prior stress testing results when possible before advanced cardiac imaging; documentation of these tests should be included with requests.

• Effort should be made to obtain copies of abnormal ECGs to determine whether an ETT would be interpretable.
• Most recent prior stress test and its findings should be provided when relevant.

Stepwise evaluation required before AQMBF in non‑obstructive CAD

For suspected or known non‑obstructive CAD (MINOCA/INOCA/ANOCA), AQMBF (e.g., PET MPI with +78434 or stress cardiac MRI with AQMBF add‑ons) is indicated after prior medical management and/or prior functional testing when symptoms persist.

• Authorization should document prior medical therapy attempted (beta‑blocker, CCB, nitrates, ranolazine, ACE‑I) or prior functional testing results.
• AQMBF is a stepwise escalation after noninvasive/medical management per guideline criteria.

One repeat TTE allowed to perform agitated saline/contrast study

One repeat echocardiogram is medically necessary specifically to perform an agitated saline (bubble) or contrast study if contrast was not administered on the initial study and the initial results indicate the need.

Echocardiography preferred first; use nuclear studies when echo inadequate or discordant

Echocardiography (TTE) is the preferred initial modality to assess left ventricular function; nuclear studies (MUGA, MPI) are appropriate when echocardiography is technically limited or results are discordant and the results will affect management.

• When echocardiography is limited, MUGA or MPI may be authorized if quantitative LVEF measurement will change clinical management (e.g., ICD candidacy, cardiotoxic therapy decisions).

Requests evaluated by evidence‑based criteria; include supporting documentation

Requests will be evaluated using evidence‑based criteria; include supporting documentation demonstrating clinical utility and alignment with guideline indications.

• Imaging requested for data collection or not used in direct clinical management may be considered not medically necessary.

Required clinical documentation to support imaging requests

Submit pertinent clinical documentation since onset or change in symptoms including detailed history, physical exam, appropriate laboratory studies, and prior imaging to establish medical necessity for advanced imaging.

• Include vital signs, height/weight/BMI or habitus description and a clear clinical question describing how imaging will affect management.
• For stress imaging, document prior PCI/CABG history, timing of troponin elevation relative to prior testing, and details of prior ETT/exercise ECG when applicable.

Document physician supervision/participation for 3D rendering

For 3D reconstruction/post‑processing, document the physician's supervision or participation, including the anatomic region to be reconstructed, tissue types/structures to display, planned outputs (images/cine loops), and intended clinical use.

• Documentation of concurrent supervision of the 3D post‑processing is recommended per ACR and required when submitting for prior authorization of 3D codes.

Use CPT 76140 for interpretation of outside studies

When interpreting an outside exam performed at another facility, use CPT 76140 for interpretation of the outside study rather than reporting another diagnostic imaging code for that prior exam.

• If the outside exam is used for comparison with a current exam, include the comparison in the diagnostic code for the current examination.

Pertinent clinical evaluation required before advanced imaging

A pertinent clinical evaluation since the onset or change in symptoms is required prior to advanced imaging; include relevant history, physical exam, labs, and prior test results when submitting requests.

• Effort should be made to obtain copies of abnormal ECGs and the most recent prior stress test.

Required clinical documentation specifics for stress testing

For stress testing requests, documentation should support prior history (e.g., PCI or CABG), timing of troponin elevation relative to testing, exercise ECG details, and symptom description to justify modality selection.

• Document reasons why ETT is not appropriate or is inconclusive, when applicable (e.g., ECG uninterpretable, inability to achieve 85% MPHR).

Include clinical signs, symptoms, or diagnostic test results in requests

Clinical signs, symptoms, or diagnostic test results supporting medical necessity (e.g., chest pain, dyspnea, abnormal ECG, elevated cardiac biomarkers) must be included with imaging requests.

• Include objective findings and how imaging results will affect management decisions.

Document clinical indication for repeat studies

Clinical documentation must support a change in status or the listed indications for repeat studies (for example: new murmur, MI/ACS, worsening heart failure, elevated BNP); absence of such documentation may lead to denial.

• If requesting repeat TTE outside routine intervals, clearly document the clinical trigger or change in status.

TTE study standards and performance requirements

Transthoracic echocardiography (TTE) should be performed as a comprehensive study with multiple acoustic windows, 2D imaging, measurements, and Doppler, and be interpreted by qualified personnel in an accredited facility.

• Ensure study meets comprehensive TTE standards when submitting for authorization or addressing questions about adequacy.

Documentation required to establish medical necessity for TEE

Medical necessity for TEE requires documentation supporting listed indications (for example: inadequate TTE window, suspected endocarditis, intracardiac thrombus, pre‑procedural planning).

• When requesting TEE for device or procedural planning, include relevant prior imaging and clinical rationale.