Cardiac Imaging Guidelines
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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.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-05: General prerequisites for advanced cardiac imaging
Covered when ALL of the following are met:
Includes relevant history, physical exam, and appropriate laboratory studies
Effort should be made to obtain copies of reported abnormal ECGs to determine ETT interpretability
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
Obtain copies of prior abnormal ECGs and most recent stress testing findings when available
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
inv-07: Medically Necessary Indications
Stress testing with imaging is considered medically necessary in any of the following clinical settings:
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
| 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 |
| 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 |
| No codes listed |
| No codes listed |
| No codes listed |
Prior Authorization, Documentation, and Denial Risk
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.
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.
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.
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: 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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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
Document Version and Effective Date
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