CurrentevicorePolicy N/A

Cardiac Imaging Guidelines

Customize your policy alerts

Sign up for all evicore policy alerts

Know when evicore releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage and utilization guidelines for cardiac imaging procedures administered by eviCore for Cigna health benefit plans; intended to guide medical necessity and coverage determinations for providers and medical directors.

Policy Summary

Payerevicore

PolicyCardiac Imaging Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionDocument a pertinent clinical evaluation (history, exam, relevant non-advanced testing) that states how the advanced imaging will affect management before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-09-01Effective date

v2.0.2026Document version

CD-1.0–CD-15.4Sections referenced

>=100CAC threshold

15+

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentevicorePolicy N/A

Cardiac Imaging Guidelines

Customize your policy alerts

Sign up for all evicore policy alerts

Know when evicore releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerevicore

PolicyCardiac Imaging Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionDocument a pertinent clinical evaluation (history, exam, relevant non-advanced testing) that states how the advanced imaging will affect management before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-09-01Effective date

v2.0.2026Document version

CD-1.0–CD-15.4Sections referenced

>=100CAC threshold

15+

Coverage and Medical Necessity Criteria

inv-05: General prerequisites for advanced cardiac imaging

Covered when ALL of the following are met:

Clinical evaluation: A pertinent clinical evaluation since onset or change in symptoms is documented

Includes relevant history, physical exam, and appropriate laboratory studies

Prior non-advanced testing: Relevant recent non-advanced tests are available (ECG, chest x-ray, or echocardiogram/ultrasound) and most recent prior stress testing findings are obtained

Effort should be made to obtain copies of reported abnormal ECGs to determine ETT interpretability

Vital signs and habitus documented: Vital signs, height and weight, BMI, or description of general habitus is documented

Clinical question: A clear clinical question that advanced imaging will answer and that will affect management is documented

Imaging is not medically necessary if results will not affect management; if catheterization/angiography already planned, advanced stress imaging often unnecessary

inv-06: General prerequisites for advanced cardiac imaging and ETT

Covered when ALL of the following are met

Pertinent clinical evaluation before imaging: A pertinent clinical evaluation since onset or change in symptoms is required, including relevant history, physical exam, appropriate labs and non-advanced imaging performed after symptoms started or worsened; documentation must state how imaging will affect management.

Obtain copies of prior abnormal ECGs and most recent stress testing findings when available

ETT-specific requirements: For consideration of ETT (exercise treadmill test) the ECG must be interpretable for ischemia and the individual must be capable of exercise to achieve target heart rate (85% of MPHR) with functional capacity ≥5 METs.Functional capacity ≥5 METs; target HR = 85% of (220 - age)

An abnormal ETT includes ST depression ≥1.0 mm, development of chest pain, systolic BP drop >10 mmHg during exercise, or ventricular tachycardia as defined in the guideline

Exceptions and surveillance: Clinical evaluation may be unnecessary for guideline-supported scheduled follow-up imaging or routine surveillance; some condition-specific sections may require face-to-face evaluation while other meaningful contact can substitute.

inv-07: Medically Necessary Indications

Stress testing with imaging is considered medically necessary in any of the following clinical settings:

Cardiac chest pain: New, recurrent, or worsening cardiac chest pain as defined in General Guidelines (CD-1.0)

Symptomatic with known CAD: Prior history of PCI or CABG or history of obstructive CAD AND any of: cardiac chest pain, anginal equivalents (atypical chest pain, exertional dyspnea, exertional fatigue), or symptoms similar to a prior ischemic episode

Newly elevated troponin with known CAD: Prior history of PCI or CABG or history of obstructive CAD AND a new troponin elevation after the last evaluation with stress test, CCTA, or diagnostic cardiac catheterization

Symptomatic and does not meet ETT requirements: New, recurrent, or worsening chest pain or exertional symptoms not explained by another process AND the individual does not meet medically necessary components for an ETT due to baseline ECG findings (eg, complete LBBB, ventricular paced rhythm, pre-excitation), significant ST depression ≥1.0 mm, LVH with strain, T wave inversion in ≥2 contiguous inferior/lateral leads, digitalis use, inability to perform exercise to achieve target HR (eg gait disturbance, home oxygen, activity-limiting dyspnea), provider assessment that ETT is unsafe, unstable angina/recent troponin, severe aortic valve disease, or uncontrolled severe hypertension

Cardiac imaging is considered not medically necessary when the results will not influence clinical management decisions. In particular, imaging stress testing is often unnecessary when a plan for invasive evaluation (for example, cardiac catheterization or other angiography) has already been made, because the imaging result would not change management.

Before advanced cardiac imaging is requested, a pertinent clinical evaluation since symptom onset or change is expected; this evaluation should document the specific clinical question that the imaging will answer and demonstrate how the result will affect management. Absent that linkage, the study may be denied as not medically necessary.

Imaging stress testing is not medically necessary when it will not change clinical management. Requests for stress imaging should therefore include documentation that the test outcome will affect care; if catheterization or other definitive invasive testing has already been decided, stress imaging is usually unnecessary.

When determining whether an exercise or imaging stress test is appropriate, reviewers evaluate whether the individual meets the clinical indications for testing and whether baseline factors limit interpretability of an exercise ECG; if the ETT would be uninterpretable or the individual cannot safely exercise, imaging modalities are preferred (see ETT limitations).

An Exercise Treadmill Test (ETT) without imaging is not appropriate when the resting ECG is uninterpretable for ischemia due to specific baseline abnormalities. Examples that render an ECG uninterpretable include complete left bundle branch block, ventricular paced rhythm, pre-excitation patterns (e.g., Wolff–Parkinson–White), left ventricular hypertrophy with strain, T-wave inversion in ≥2 contiguous inferior/lateral leads, digitalis therapy, or ≥1.0 mm baseline ST depression.

In such situations where the ECG is not interpretable or the individual cannot achieve or safely perform the required exercise (see ETT functional capacity requirements), stress imaging (stress echo, SPECT/PET MPI, or stress cardiac MRI) is indicated instead.

When advanced imaging is part of a guideline-supported, scheduled follow-up or routine surveillance pathway, a face-to-face clinical evaluation may not be required. The policy notes that other meaningful contact (telephone, electronic messaging) by an established clinician can substitute for an in-person visit in many cases, though some condition-specific sections may still require face-to-face assessment.

Documentation expectations remain: even when evaluation can be remote, requests should include relevant history, any recent non-advanced testing (ECG, chest x-ray, echocardiogram), vital signs, habitus (height/weight/BMI or description), and the clinical question that the imaging will answer.

Cardiac imaging is unnecessary when it will not change management decisions. The policy specifically states that if a decision to perform cardiac catheterization or other angiography has already been made, imaging stress testing is often not needed because the result will not influence the planned invasive management.

Requests for imaging that duplicate information already available or that are intended after invasive management has been decided are at high risk for denial unless clear, new management‑altering rationale is provided.

No coverage criteria are provided in this portion of the Table of Contents excerpt.

No detailed coverage criteria are present in this excerpt of the Table of Contents; substantive criteria appear in other sections of the guideline not included here.

This Table of Contents entry is a navigation placeholder; no criteria are provided in this excerpt.

Referenced Codes and Radiation Dose Estimates

Estimated effective radiation doses for selected imaging studiesmixed

Rubidium-82 / N-13 ammonia PET MPI	Estimate of Effective Radiation Dose = 2 mSv
Thallium dual isotope MPI (3.5 mCi Tl-201 rest / 30 mCi 99mTc stress)	Estimate of Effective Radiation Dose = 23 mSv
Diagnostic conventional coronary angiogram (catheterization)	Estimate of Effective Radiation Dose = 2 mSv to 22 mSv
Coronary computed tomography angiography (CCTA)	Estimate of Effective Radiation Dose = 8.7 mSv
Cardiac CT calcium scoring	Estimate of Effective Radiation Dose = 1 mSv to 5 mSv
CT Abdomen and Pelvis	Estimate of Effective Radiation Dose = 7.7 mSv
Chest x-ray	Estimate of Effective Radiation Dose = 0.1 mSv

Covered CPT CodesCPTCovered

75559	Cardiac MRI for morphology and function without contrast, with stress imaging
75563	Cardiac MRI for morphology and function without and with contrast, with stress imaging
0899T	AQMBF MRI augmentative algorithmic analysis (list separately)
0900T	AQMBF MRI assistive algorithmic analysis (list separately)
78434	AQMBF PET (absolute quantitation of myocardial blood flow)
78451	Myocardial perfusion imaging, SPECT, tomographic (including attenuation correction)
78491	Myocardial imaging, PET, perfusion study; single study at rest or stress
78492	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress
93350	Stress echocardiogram (TTE) during rest and cardiovascular stress
93351	Stress echocardiogram (2D) during rest and cardiovascular stress test

Referenced coding sourcesmixed

No codes listed

No codes listedmixed

No codes listed

Referenced policy sections (no codes listed)mixed

No codes listed

Double Product (Rate Pressure Product)

Double Product (Rate Pressure Product)Index of cardiac oxygen consumption calculated as systolic blood pressure × heart rate; over 25,000 indicates an adequate stress load was performed.

Exercise functional capacity (ETT) — Key requirements

Exercise functional capacity (ETT) — METs threshold>= 5 METs is required for diagnostic ETT (functional capacity criteria).

ETT target heart rateTarget heart rate = 85% of maximum predicted heart rate (MPHR); MPHR = 220 − age.

ECG requirementECG must be interpretable for ischemia for a diagnostic ETT.

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Prior authorization required for stress imaging and AQMBF

Prior authorization is required for stress testing with imaging per the Stress Testing with Imaging guideline; when AQMBF is performed with PET or MRI, add CPT 78434 (AQMBF PET) or CPT 0899T/0900T (AQMBF MRI) in addition to the primary procedure code.

AQMBF PET — CPT 78434 (list separately in addition to primary procedure)
AQMBF MRI — CPT 0899T or 0900T (when included with cardiac MRI stress perfusion)

Prior Authorization

Document clinical evaluation before authorization

A clinical evaluation documenting subjective and objective findings and a clear clinical question that the advanced imaging will answer and that will affect management is required before considering advanced cardiac imaging.

Include relevant history, physical exam, and appropriate laboratory studies.
Document how imaging results will affect clinical management.

Policy Background and Scope

This evidence-based coverage policy was developed by eviCore to guide interpretation of Cigna standard benefit plans for cardiac imaging. It is intended to inform medical necessity and coverage determinations and is not a treatment guideline; specific plan documents may supersede the policy.

Key Definitions and Abbreviations

Coverage policies definition

Purpose of coverage policiesGuidance for interpreting standard Cigna benefit plans and used by medical directors and other health professionals in making medical necessity and other coverage determinations; not treatment recommendations.

CPT definition

CPT definitionCurrent Procedural Terminology (CPT) five‑digit codes, nomenclature and related data are AMA copyright material referenced by the policy.

Module identifiers

Module identifiers — examplesSection codes used to identify guideline modules referenced in the Table of Contents (e.g., CD‑5.2, CD‑7.3).

Document Version and Effective Date

Revision history placeholder

Revision history placeholderNo codes listed in this excerpt — Table of Contents placeholder for revision history area.

Not medically necessary (NMN) placeholder

NMN statements placeholderNo explicit 'not medically necessary' statements present in this Table of Contents segment.

Document version and effective date

Document version and effective dateVersion v2.0.2026; Effective date displayed as 2026-09-01.

Policy Summary

Payerevicore

PolicyCardiac Imaging Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionDocument a pertinent clinical evaluation (history, exam, relevant non-advanced testing) that states how the advanced imaging will affect management before requesting authorization.

SourceLink

On This Page

Suspected/known non-obstructive CAD (AQMBF only): Stress imaging with AQMBF (PET or stress cardiac MRI with AQMBF) for suspected or known non-obstructive CAD (MINOCA, INOCA, ANOCA) when there is a normal or equivocal ETT OR diagnosis of no obstructive CAD on CCTA or invasive angiography AND either persistent symptoms despite medical management (beta-blockers, CCBs, nitrates, ranolazine, ACE‑Is) OR functional testing demonstrates ischemia

Symptomatic with inconclusive/abnormal ETT or elevated CAC: New, recurrent, or worsening chest pain or exertional symptoms AND any of: inconclusive ETT (<85% MPHR achieved or exercise ECG uninterpretable), abnormal ETT with horizontal/downsloping ST depression ≥1.0 mm, development of chest pain during test, drop in systolic BP >10 mmHg during exercise, non‑sustained or sustained VT as defined, OR coronary artery calcium (CAC) score ≥100CAC ≥100; <85% MPHR for inconclusive ETT

Coronary artery calcium (CAC) score

Coronary artery calcium (CAC) score threshold>= 100 (CAC score ≥100 considered elevated and referenced as indication in symptomatic individuals).

Prior Authorization

Prerequisites required for prior authorization

Prior authorization requires documentation that the clinical evaluation occurred after symptom onset or change and evidence regarding ECG interpretability for ischemia (or reasons it is uninterpretable); for ETT, document functional capacity and ability to exercise when applicable.

Obtain copies of reported abnormal ECGs to assess ETT interpretability.
Document functional capacity (≥5 METs) and ability to achieve target HR when ETT is requested.

Step Therapy

Obtain prior non-advanced testing when available

Effort should be made to obtain prior non-advanced studies and most recent stress testing results before advanced imaging authorization is requested.

Obtain recent ECG and copies of abnormal ECGs when relevant.
Obtain recent chest x-ray and echocardiogram/ultrasound reports when available.
Provide most recent previous stress testing results and findings.

Denial Risk

Denial risk: imaging that won't affect management

Imaging may be denied as not medically necessary when the results will not affect clinical management decisions—for example, if cardiac catheterization or other angiography has already been decided.

If the decision for invasive angiography is already made, advanced stress imaging is often unnecessary.

Denial Risk

Requests outside listed indications may be denied

Requests for stress testing with imaging that do not match the listed medically necessary clinical settings risk denial or may require additional documentation to support medical necessity.

Medically necessary settings include acute/recurrent/worsening chest pain, symptomatic known CAD, newly elevated troponin with known CAD, inability to perform interpretable ETT, suspected/known non-obstructive CAD meeting AQMBF criteria, or symptomatic with inconclusive/abnormal ETT or elevated CAC.

Denial Risk

Determination basis and denial risk

Coverage determinations consider the applicable benefit plan document, applicable laws and regulations, relevant collateral source materials including coverage policies, and the specific facts of the situation; conflicts are resolved in favor of the customer's benefit plan document.

Providers should ensure requests and documentation align with the member's benefit plan terms.

Documentation Required

Documentation required to support medical necessity

Providers must document information necessary to support medical necessity consistent with the applicable benefit plan and relevant laws/regulations, using coverage policies as collateral source material.

Include pertinent history, physical exam, appropriate labs, non-advanced imaging, vital signs, habitus (height/weight/BMI), and the clinical question the imaging will answer.

Note

AQMBF indicated for suspected/known non‑obstructive CAD

AQMBF PET MPI or stress cardiac MRI with AQMBF is indicated for suspected or known non-obstructive CAD when persistent symptoms occur despite prior medical management or when functional testing demonstrates ischemia, provided prior testing (normal/equivocal ETT or CCTA/invasive angiography showing no obstructive CAD) is documented.

AQMBF PET — CPT 78434; AQMBF MRI — CPT 0899T/0900T when performed with stress perfusion studies.
Persistent symptoms despite optimized medical therapy or evidence of ischemia on functional testing are required.

Note

Prior authorization details not provided in this excerpt

This Table of Contents excerpt does not specify prior authorization rules or list the codes subject to prior authorization in these chunks.

Refer to the full guideline sections referenced in the TOC for specific prior authorization code lists and rules.

Note

TOC references prior authorization sections (details elsewhere)

The Table of Contents points to sections (for example, CD-7.2–CD-7.7) where prior authorization rules and coding notes may be specified, but those rules are not stated in these TOC chunks.

Check the referenced guideline sections for specific prior authorization instructions.

Note

Prior authorization not specified in this section

Prior authorization requirements are not specified in the Table of Contents fragments provided here; the TOC entries are placeholders and do not include authorization instructions.

Providers should consult the full policy text for explicit prior authorization rules.

Note

Prior authorization not specified in TOC fragments

The Table of Contents fragments in this excerpt are navigation entries only and do not specify prior authorization requirements or procedures.

Use the full guideline sections for actionable prior authorization instructions.

Note

Prior authorization referenced but not detailed here

Prior authorization is referenced in TOC placeholders throughout these excerpts but the specific authorization rules are not provided in these chunks.

Confirm authorization requirements in the detailed policy sections.

Denial Risk

Imaging unnecessary when it won't change management

Cardiac imaging is not medically necessary if the results will not affect clinical management decisions; imaging stress testing is often unnecessary if a decision for cardiac catheterization or other angiography has already been made.

Document the clinical question and intended management change to justify imaging.

TGATransposition of the Great Arteries (abbreviation as listed in TOC).

Abbreviations

ASDAtrial Septal Defects (abbreviation as listed in TOC).

Module reference — perinatal/maternal imaging

CD-15.1–CD-15.4Perinatal/maternal imaging sections referenced in the Table of Contents (CD‑15.1 through CD‑15.4).

Module reference — cardiotoxicity

CD-12Cardiotoxic Agent‑Related Cardiac Dysfunction section referenced in the Table of Contents (CD‑12).

CD-3.9 reference

CD-3.9 referencedCardiac Sarcoidosis (CD‑3.9) is listed and cross‑referenced in the Table of Contents.

Cardiac Sarcoidosis label

Cardiac Sarcoidosis (CD-3.9)Referenced guideline section label for Cardiac Sarcoidosis as shown in the Table of Contents.

Myocardial Tc-99m Pyrophosphate Imaging label

Myocardial Tc-99m Pyrophosphate Imaging (CD-3.8)Referenced guideline section label for imaging in cardiac amyloidosis (CD‑3.8) as shown in the Table of Contents.

Cardiotoxic Agent-Related Cardiac Dysfunction label

Cardiotoxic Agent-Related Cardiac Dysfunction (CD-12)Referenced guideline section label for cardiotoxic agent‑related cardiac dysfunction (CD‑12).

CD-3.8 identifier (reference)

CD-3.8 identifierReferenced section identifier for Myocardial Tc‑99m Pyrophosphate Imaging in Cardiac Amyloidosis (CD‑3.8) noted in TOC.

CD-3.9 identifier (reference)

CD-3.9 identifierReferenced section identifier for Cardiac Sarcoidosis (CD‑3.9) noted in TOC.

CD-10.1 identifier (reference)

CD-10.1 identifierReferenced section identifier for Cardiac Trauma Imaging (CD‑10.1) noted in TOC.

CD-12 identifier (reference)

CD-12 identifierReferenced section identifier for Cardiotoxic Agent‑Related Cardiac Dysfunction (CD‑12) noted in TOC.

Congenital identifiers

CD-11.3.9 / CD-11.3.10Section identifiers referenced for Transposition of the Great Arteries (CD‑11.3.9) and Congenitally Corrected TGA (CD‑11.3.10).

Myocardial Tc-99m Pyrophosphate Imaging (reference)

Myocardial Tc-99m Pyrophosphate Imaging referenced (CD-3.8)CD‑3.8 is the guideline section referenced for Myocardial Tc‑99m Pyrophosphate Imaging in Cardiac Amyloidosis.

Acute Chest Pain

Acute Chest Pain definitionChest pain that is new onset (<2 months) or involves a change in pattern, intensity, or duration compared with previous episodes in an individual with recurrent symptoms.

Acute Coronary Syndrome (ACS)

Acute Coronary Syndrome (ACS) definitionSudden imbalance between myocardial oxygen consumption and demand, usually related to coronary artery obstruction; includes unstable angina, STEMI and NSTEMI.

Optimized Medical Therapy

Optimized Medical TherapyTherapy should include, where tolerated, antiplatelet agents, calcium channel antagonists, partial fatty acid oxidase inhibitors (e.g., ranolazine), statins, short‑acting nitrates as needed, long‑acting nitrates up to 6 months post‑ACS, and optionally beta blockers and ACE‑Is/ARBs.

Cardiac chest pain (likely angina)

Cardiac chest pain (likely angina) — descriptorsRetrosternal chest discomfort described as pain, pressure, squeezing, heaviness, tightness, or burning, possibly radiating to left arm/neck/jaw/back; precipitated by exercise or stress and relieved with rest or nitroglycerin.

Possible cardiac chest pain (atypical)

Possible cardiac chest pain (atypical)Symptoms suggestive of cardiac origin but lacking definitive features or occurring in a time course not suggestive of angina; may occur with mild associated symptoms or some risk factors without diagnostic confirmation.

AQMBF definition

AQMBF definitionAbsolute quantitation of myocardial blood flow (AQMBF) — noninvasive measurement derived via PET (CPT 78434) or MRI (CPT 0899T/0900T) when included with cardiac PET perfusion or stress cardiac MRI.

ETT definition

ETT definitionExercise treadmill test (ETT): an unenhanced exercise ECG stress test; diagnostic ETT requires interpretable ECG and ability to exercise to target HR (85% MPHR) with functional capacity ≥5 METs.