CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Myocardial Perfusion Imaging (Exercise and Pharmacologic Nuclear Stress Tests)

Clinical review criteria governing medical necessity determinations and authorization guidance for myocardial perfusion imaging (exercise and pharmacologic nuclear stress tests) for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyMyocardial Perfusion Imaging (Exercise and Pharmacologic Nuclear Stress Tests) Clinical Review Criteria

Policy CodePolicy N/A

Change TypeCriteria updatesCPT code updateMedicare MA review initiation

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization/medical necessity review for listed myocardial perfusion imaging CPT codes and provide the last 6 months of clinical notes to support the request.

SourceLink

POLICY UPDATE CHANGES

Initiation of medical necessity review of MPI for Medicare Advantage members to align with 2024 CMS final rule, effective February 1, 2024.

Updated the hybrid criteria to improve performance of the MPI criteria, effective February 1, 2024.

Updated applicable CPT codes for myocardial perfusion imaging.

3CPT codes listed for MPI (78451-78454)

20%Estimated contribution to US annual radiation dose

2Stress modalities covered

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Coverage and Medical Necessity Criteria

Medical Necessity Criteria

Considered medically necessary when the applicable policy statements or MCG guideline criteria for exercise or pharmacologic MPI are met:

Medicare and Non-Medicare criteria: Medicare members: follow the applicable policy statements and CMS/LCD guidance listed; Non-Medicare members: follow the MCG Myocardial Perfusion Imaging Exercise Stress (KP-0078) or Pharmacologic Stress (KP-0079) criteria selected by Kaiser Permanente.

See referenced CMS/LCD guidance for Medicare members and MCG KP-0078/KP-0079 for non-Medicare members.

MCG manuals used to inform utilization decisions are proprietary and are not published in this document. On an individual member basis, Kaiser Permanente can share the specific MCG criteria document used for a utilization management decision upon request; contact the Kaiser Permanente Clinical Review staff to request a copy.

These Clinical Review Criteria are developed to assist in administering plan benefits and do not guarantee coverage. Kaiser Permanente may modify or revoke these criteria at its discretion, and member contracts differ; always consult the patient’s Evidence of Coverage or contact Kaiser Permanente Member Services to determine whether a specific service is covered for an individual member.

Applicable Codes

Applicable CPT Codes for Myocardial Perfusion ImagingCPTCovered

78451	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic).
78452	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.
78453	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic).
78454	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Pre-authorization/medical necessity review is required for the listed myocardial perfusion imaging (MPI) CPT codes. Verify specific plan pre-authorization requirements using the member's plan details and the Pre-authorization Code Check.

Applicable CPT codes: 78451, 78452, 78453, 78454
Medicare: Considered medically necessary when criteria in the applicable policy statements are met
Non‑Medicare: Kaiser Permanente uses MCG guidelines (Exercise Stress KP-0078 and Pharmacologic Stress KP-0079) for medical necessity determinations

Documentation Required

When requesting these services, provide supporting clinical documentation to facilitate medical necessity review.

Include the last 6 months of clinical notes from the requesting provider and/or specialist

Background

Myocardial perfusion imaging (SPECT) involves intravenous injection of a radiotracer to visualize myocardial blood perfusion. Defects that appear with stress but not at rest suggest inducible ischemia. Gated SPECT synchronizes imaging with the ECG to assess ventricular function, including ejection fraction, in addition to perfusion. When exercise is not feasible, pharmacologic stress agents such as adenosine, dipyridamole, regadenoson, or dobutamine are used to induce coronary hyperemia; note that some agents (eg, adenosine, dipyridamole) are contraindicated in severe reactive airway disease.

Definitions

Gated SPECT (definition and key points)

TermGated SPECT

DefinitionMyocardial perfusion imaging synchronized with ECG that can assess ventricular function, including ejection fraction, in addition to myocardial perfusion.

Clinical utilityMost useful for patients at intermediate risk for coronary artery disease, those needing management or prognostic information, or with unexplained persistent symptoms.

Modality noteAvailable as part of SPECT systems and hybrid SPECT/CT systems to improve diagnostic assessment.

Radiation considerationContributes substantially to collective radiation exposure; best-practice methods recommended to maximize diagnostic quality while minimizing dose.

Pharmacologic stress agents (definition and key points)