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    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingTexas Children's SPECT Prior Auth | OpenPayer
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    CurrentTexas Children's Health PlanPolicy 6201

    Single Photon Emission Computed Tomography (SPECT) Scan Guidelines

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    This guideline governs prior authorization and medical-necessity review for all SPECT scans requested for Texas Children's Health Plan members. It identifies required submission documentation, covered clinical indications, and non-covered or experimental/investigational uses.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicySingle Photon Emission Computed Tomography (SPECT) Scan Guidelines
    Policy CodePolicy 6201
    Change TypeNo material change
    Effective DateAug 31, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization for every requested SPECT scan and submit the diagnosis, treatment history, treatment plan, current medications, previous imaging results, and signed physician order.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AllSPECT scans requiring prior authorization
    6Required documentation elements
    11Medically necessary non-cardiac indication categories
    35Non-cardiac excluded uses

    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.

    12Cardiac exclusion scenarios
    1–2 yearsRepeat-imaging exclusion intervals

    Coverage Criteria

    Cardiac medically necessary indications

    SPECT is medically necessary when at least one of the following cardiac indications is present:

    Cardiac indications

    • CAD with abnormal resting ECG and restricted exercise intolerance: Diagnosis of coronary artery disease with an abnormal resting electrocardiogram and restricted exercise intolerance.

    • Prognosis assessment when non-nuclear stress testing is impeded or contraindicated

      • Supporting circumstance

        • Physical impairment: A physical impairment precludes physically performing the exercise portion of a stress test.
        • Prior ischemic event: History of a prior proven ischemic cardiac event.
        • Previously proven CAD: Coronary artery disease proven by prior SPECT or coronary catheterization.
        • Uninterpretable ECG: ECG findings would prevent interpretation of standard stress testing, including left bundle branch block, paced rhythm, Wolff-Parkinson-White syndrome, left ventricular hypertrophy with ST-segment depression, or digoxin use.
        • CHF with revascularization: History of congestive heart failure with a history of revascularization.

          Repeat nuclear imaging as frequently as annually may be medically necessary.

    • Myocardial viability: Assessment of myocardial viability before referral for revascularization.

    Non-cardiac medically necessary indications

    SPECT is medically necessary for non-cardiac indications when the applicable clinical condition and specified technique are present:

    Non-cardiac indications

    • Brain tumors: Differentiate lymphoma from infection such as toxoplasmosis, particularly in immunosuppressed members, or distinguish recurrent tumor from radiation changes when PET is unavailable.
    • Liver hemangioma: Use labeled red blood cells to further define lesions identified by other imaging modalities.
    • Abscess, infection, inflammation, or fever of unknown origin: Localize abscess, infection, or inflammation in soft tissues or evaluate fever of unknown origin.
    • Neuroendocrine tumors: Evaluate neuroendocrine tumors, including adenomas, carcinoid, pheochromocytomas, neuroblastoma, VIP-secreting tumors, thyroid carcinoma, or adrenal gland tumors, using OctreoScan or I-131 MIBG.

    Non-cardiac experimental or not medically necessary indications

    SPECT is experimental/investigational and not medically necessary for any of the following non-cardiac indications:

    Excluded non-cardiac indications

    • Behavioral or neuropsychiatric conditions: Attention deficit/hyperactivity disorder; autism; personality disorders; schizophrenia; neuropsychiatric disorders without evidence of cerebrovascular disease; or pervasive developmental disorders.
    • Stroke and neurologic conditions: Stroke evaluation; differential diagnosis of Parkinson disease from other Parkinsonian syndromes; multiple sclerosis; head trauma; generalized pain or insomnia; chronic fatigue syndrome; pre-diagnostic Parkinson disease imaging markers; progressive supranuclear palsy; or corticobasal syndrome.
    • Dementia: Initial or differential diagnosis of suspected dementia, including Alzheimer disease, dementia with Lewy bodies, frontotemporal dementia, or vascular dementia.

    Cardiac exclusion criteria

    Cardiac SPECT is experimental/investigational and not medically necessary for any of the following ACC-inappropriate uses:

    • Routine post-procedure screening: Routine screening after PTCA with or without stenting or CABG before discharge from acute care; or routine screening less than 2 years after PTCA with stenting or CABG when symptoms have not worsened, the member had symptoms before intervention, and there is no history of congestive heart failure.Less than 2 years
    • Vulnerable plaque: Assessment of vulnerable plaque.
    • Acute unstable cardiac event: Evaluation of acute coronary event with hemodynamic instability, shock, or mechanical complications; or acute chest pain or equivalent symptoms with high likelihood of acute coronary syndrome, diagnosed acute myocardial infarction, immediate post-thrombolytic period, or marked ST-segment elevation indicating high pretest likelihood of significant coronary disease.

    SPECT is not medically necessary for the evaluation or management of cerebrovascular accident (CVA or stroke), subarachnoid hemorrhage, or transient ischemic attack.

    SPECT is considered experimental/investigational and not medically necessary for the enumerated non-cardiac uses because diagnostic value has not been established in the peer-reviewed medical literature. Excluded uses include behavioral or neuropsychiatric conditions such as attention deficit/hyperactivity disorder, autism, personality disorders, schizophrenia, neuropsychiatric disorders without evidence of cerebrovascular disease, and pervasive developmental disorders; stroke evaluation; differential diagnosis of Parkinson disease from other Parkinsonian syndromes; multiple sclerosis; head trauma; generalized pain or insomnia; chronic fatigue syndrome; suspected dementia; and pre-diagnostic Parkinson disease imaging markers, progressive supranuclear palsy, or corticobasal syndrome.

    Excluded applications also include colorectal, prostate, breast, lung, ovarian, and other malignancies not listed as medically necessary; DaT scans for all indications; endoleak; pre-surgical lung-volume-reduction evaluation; prosthetic graft infection; carotid balloon-occlusion scanning; vasculitis; air leak or pneumothorax; salivary gland dysfunction; painful legs and moving toes syndrome; carotid stenosis; surgical planning for axial neck or back pain from disc degeneration or spondylolysis; SPECT-CT fusion other than parathyroid imaging; SPECT/ultrasonography fusion for thyroid disease; and pre-surgical workup for non-cardiac surgery.

    Cardiac SPECT is considered experimental/investigational and not medically necessary for ACC-inappropriate uses, including routine screening after PTCA or CABG before discharge; routine screening less than 2 years after PTCA with stenting or CABG when symptoms have not worsened, symptoms were present before intervention, and there is no history of congestive heart failure; vulnerable-plaque assessment; and evaluation during an acute coronary event with hemodynamic instability, shock, or mechanical complications.

    Exclusions also include acute chest pain or equivalent symptoms with high likelihood of acute coronary syndrome, diagnosed acute myocardial infarction, the immediate post-thrombolytic period, or marked ST-segment elevation; preoperative testing before high-risk surgery when recent cardiac catheterization, coronary intervention, CABG, or nuclear stress testing was normal within 1 year; preoperative testing before intermediate-risk non-cardiac surgery when standard stress testing can be performed without contraindication; and testing before low-risk non-cardiac surgery for risk assessment. Screening or reassessment is also excluded for low-probability coronary disease with a Framingham score less than 10 and no diabetes, for high-risk asymptomatic members less than 2 years after an initial negative radionuclear study, and for stable known coronary disease less than 1 year after the last radionuclear study when there is no prior infarction.

    SPECT is not medically necessary for evaluation or management of cerebrovascular accident, subarachnoid hemorrhage, or transient ischemic attack.

    All other non-cardiac indications not established as medically necessary under this guideline are not medically necessary, including the specifically enumerated experimental or investigational uses. These include behavioral, neuropsychiatric, neurologic, dementia, pain, insomnia, head-trauma, and selected Parkinsonian applications; malignancies not listed as medically necessary; DaT scans for all indications; vascular, pulmonary, salivary-gland, thyroid-fusion, prosthetic-graft, and other listed applications; non-parathyroid SPECT-CT fusion; and pre-surgical workup for non-cardiac surgery.

    Myocardial sympathetic innervation imaging, with or without SPECT, is considered experimental and investigational because its effectiveness has not been established. The service is therefore not medically necessary under this guideline.

    Clinical Risk and Timing Definitions

    High-risk surgery
    Risk thresholdCardiac death or myocardial infarction risk greater than 5%
    ExamplesEmergent major operations, aortic and peripheral vascular surgery, and prolonged procedures with large fluid shifts or blood loss
    Preoperative useCardiac SPECT is not medically necessary before high-risk surgery when the member is asymptomatic and recent cardiac testing was normal within the prior year
    Intermediate-risk surgery
    Risk thresholdCardiac death or myocardial infarction risk from 1% to 5%
    ExamplesCarotid endarterectomy, head and neck surgery, chest or abdominal surgery, orthopedic surgery, and prostate surgery

    Authorization and Submission Requirements

    Prior Authorization

    Prior Authorization Required for All SPECT Scans

    Prior authorization is required for all Single photon emission computed tomography (SPECT) scans. Requests are received by the Utilization Management Department through online submission, fax, phone, or mail and are processed during normal business hours.

    • Submit all SPECT scan authorization requests to Utilization Management through an approved submission channel.
    Note

    Authorization Is Not a Benefit Guarantee

    Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility. Approval applies only to the medical necessity of the requested service; all services remain subject to applicable benefit limitations and exclusions. Providers must comply with state and federal regulatory requirements, and noncompliance may result in retrospective audit and potential financial recoupment.

    • Verify member eligibility and benefit coverage separately from authorization approval.
    • Authorization does not override benefit limitations or exclusions.

    Clinical Background

    Single photon emission computed tomography (SPECT) is a three-dimensional nuclear imaging modality that depicts the concentration of a radiopharmaceutical within tissues and organs. The guideline addresses cardiac and non-cardiac applications, including myocardial viability, selected tumor and infection evaluations, renal scarring and function, pulmonary embolism assessment, epilepsy localization, and bone or joint conditions. Coverage depends on the clinical indication and whether the use is established as medically necessary under the guideline.

    Definitions

    Single photon emission computed tomography (SPECT)
    ModalitySingle photon emission computed tomography (SPECT)
    Image typeProvides three-dimensional images
    What it depictsThe concentration of a radiopharmaceutical within various tissues and organs
    Surgical risk categories
    High-risk surgeryRisk of cardiac death or myocardial infarction greater than 5%
    Intermediate-risk surgeryRisk of cardiac death or myocardial infarction from 1% to 5%
    Low-risk surgery

    Medically Necessary Indications

    Cardiac disease, coronary artery disease prognosis, and myocardial viability

    SPECT is covered for cardiac disease, coronary artery disease prognosis, or myocardial viability when at least one of the following indications is present:

    Covered cardiac indications

    • CAD with abnormal resting ECG and restricted exercise intolerance: Diagnosis of coronary artery disease with an abnormal resting electrocardiogram and restricted exercise intolerance.
    • CAD prognosis with contraindication to non-nuclear testing: Assessment of prognosis in a member with coronary artery disease when non-nuclear stress testing is impeded or contraindicated, including physical inability to exercise, a prior proven ischemic cardiac event, CAD proven by prior SPECT or coronary catheterization, an uninterpretable ECG, or congestive heart failure with prior revascularization.
    • Myocardial viability: Assessment of myocardial viability before referral for revascularization.

    Repeat Imaging Limits

    SPECT frequency limit
    FrequencyRepeat nuclear imaging may be medically necessary as frequently as annually
    Applicable scenarioCardiac prognosis assessment in a member with coronary artery disease when non-nuclear stress testing is impeded or contraindicated
    Specified historyThe member has congestive heart failure with a history of revascularization
    Cardiac SPECT after revascularization
    Interval exclusionRoutine repeat cardiac SPECT is not medically necessary less than 2 years after PTCA with stenting or CABG
    Symptom conditionThe member must have no worsening in symptomatology and must have had symptoms before the intervention

    Prior Authorization

    Prior Authorization

    Authorize every SPECT study before performance

    Prior authorization is required for every requested SPECT study. Submit the request through the Utilization Management Department before the study is performed.

    Non-Covered Uses

    SPECT is not covered for cerebrovascular accident, subarachnoid hemorrhage, or transient ischemic attack; the enumerated experimental or investigational non-cardiac indications; ACC-inappropriate cardiac screening, acute-event, preoperative, or repeat-imaging scenarios; or myocardial sympathetic innervation imaging, with or without SPECT. The non-cardiac exclusions include DaT scans for all indications and SPECT-CT fusion other than parathyroid imaging.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicySingle Photon Emission Computed Tomography (SPECT) Scan Guidelines
    Policy CodePolicy 6201
    Change TypeNo material change
    Effective DateAug 31, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization for every requested SPECT scan and submit the diagnosis, treatment history, treatment plan, current medications, previous imaging results, and signed physician order.
    SourceLink
    On This Page
    Coverage CriteriaClinical Risk and Timing DefinitionsAuthorization and Submission RequirementsClinical BackgroundDefinitionsMedically Necessary IndicationsRepeat Imaging LimitsPrior AuthorizationNon-Covered Uses
  1. Parathyroid imaging: Perform parathyroid imaging, including SPECT-CT fusion, with laboratory evidence of hyperparathyroidism, enlarged parathyroid gland, parathyroid hyperplasia, or suspected parathyroid adenoma or carcinoma.
  2. Renal DMSA scan: Assess kidney scarring and function using a dimercaptosuccinic acid scan.
  3. Pulmonary embolism: Diagnose pulmonary embolism using SPECT ventilation/perfusion scintigraphy.
  4. Parkinson disease versus essential tremor: Distinguish Parkinson disease from essential tremor.
  5. Lymphoma: Distinguish tumor from necrosis in lymphoma.
  6. Presurgical seizure-focus localization: Perform presurgical ictal detection of a seizure focus in a member with epilepsy in place of PET.
  7. Bone and joint conditions: Differentiate infectious, neoplastic, avascular, or traumatic processes, including spondylolysis and stress fractures not visible on x-ray.
    8. Specified malignancies or cancer applications: Colorectal carcinoma; prostate carcinoma including ProstaScint with or without CT or MRI fusion; scintimammography for breast cancer; lung or ovarian malignancies and differentiation of malignant from benign lung lesions; or other malignancies not listed as medically necessary.
  8. Other excluded applications: Endoleak; pre-surgical lung volume reduction evaluation; prosthetic graft infection; carotid balloon-occlusion scanning; vasculitis; air leak or pneumothorax; salivary gland dysfunction; painful legs and moving toes syndrome; carotid stenosis; surgical planning for axial neck or back pain from disc degeneration or spondylolysis; SPECT-CT fusion other than parathyroid imaging; SPECT/ultrasonography fusion for thyroid disease; or pre-surgical workup for non-cardiac surgery.
  9. DaT scan: Dopamine transporter scan for all indications.
    10. Preoperative evaluation after recent normal testing: Before high-risk surgery when asymptomatic and cardiac catheterization, coronary intervention, CABG, or nuclear stress testing was normal within the prior year.Less than 1 year
  10. Intermediate-risk preoperative evaluation: Before intermediate-risk non-cardiac surgery when the member can perform and has no contraindication to standard stress testing.
  11. Low-risk preoperative evaluation: Before low-risk non-cardiac surgery for risk assessment.
  12. Low-probability or recent negative-study screening: Screening an asymptomatic member without known coronary disease who has a Framingham score less than 10 and no diabetes; screening a member with chest pain or equivalent symptoms who has a Framingham score less than 10, no diabetes, and no impediment or contraindication to non-nuclear stress testing; or reevaluation of a high-risk member without symptoms after an initial negative radionuclear study when less than 2 years have elapsed.Framingham score less than 10; or less than 2 years since negative study
  13. Stable known coronary disease reassessment: Reevaluation of a member without chest pain or equivalent symptoms or with stable symptoms and known coronary disease based on prior abnormal catheterization or SPECT, without prior infarction, when less than 1 year has elapsed since the last radionuclear study.Less than 1 year

    Worsening symptoms or silent ischemia may support more frequent imaging or other testing/intervention.

    14. Preoperative useCardiac SPECT is not medically necessary before intermediate-risk non-cardiac surgery when the member can perform standard stress testing and has no contraindication
    Low-risk surgery
    Risk thresholdCardiac death or myocardial infarction risk less than 1%
    ExamplesEndoscopic procedures, superficial procedures, cataract surgery, and breast surgery
    Preoperative useCardiac SPECT is not medically necessary before low-risk non-cardiac surgery for risk assessment
    Framingham score
    High coronary-disease riskFramingham score greater than 10
    Low coronary-disease riskFramingham score less than 10
    Screening exclusionMembers with a Framingham score less than 10 and no history of diabetes are excluded from specified cardiac SPECT screening scenarios
    Post-revascularization interval
    IntervalLess than 2 years after PTCA with stenting or CABG
    SymptomsThere must be no worsening in symptomatology, and the member must have had symptoms before the intervention
    Heart failure historyThe member must have no history of congestive heart failure
    Repeat radionuclear imaging interval
    Known coronary disease reassessmentRepeat radionuclear imaging is excluded when less than 1 year has elapsed since the last study in members with stable or no symptoms and known coronary disease based on prior abnormal catheterization or SPECT, without prior infarction
    Recent normal testing before high-risk surgeryCardiac SPECT is excluded when normal cardiac catheterization, coronary intervention, CABG, or nuclear stress testing occurred less than 1 year before surgery in an asymptomatic member
    Initial negative studyReevaluation is excluded when less than 2 years have elapsed since an initial negative radionuclear study in an asymptomatic member at high risk for coronary disease
    Documentation Required

    Required Clinical Documentation

    Provide complete clinical documentation with every SPECT scan prior authorization request.

    • Diagnosis
    • Treatment history
    • Treatment plan
    • Current medications
    • Previous imaging results
    • Signed physician order for the ordered test
    Documentation Required

    Clinical Review of Submitted Information

    The Utilization Management professional receiving the request reviews the submitted information to determine whether the documentation supports the SPECT scan request as an eligible service.

    • Ensure the clinical record supports the requested indication and includes all required documentation before submission.
    Denial Risk

    Unlisted or Experimental Non-Cardiac Uses

    SPECT is considered experimental and investigational and not medically necessary for non-cardiac indications other than those specifically established as medically necessary. Diagnostic value has not been established in the peer-reviewed medical literature for these uses.

    • Attention deficit/hyperactivity disorder; autism; personality disorders, including aggressive or violent behaviors, antisocial personality disorder or psychopathy, schizotypal personality disorder, and borderline personality disorder; schizophrenia; and neuropsychiatric disorders without evidence of cerebrovascular disease.
    • Differential diagnosis of Parkinson's disease from other Parkinsonian syndromes; imaging as a marker of pre-diagnostic Parkinson's disease; management of progressive supranuclear palsy; management of corticobasal syndrome; and dopamine transporter (DaT) scans for all indications.
    • Endo leak; generalized pain or insomnia; head trauma; multiple sclerosis; chronic fatigue syndrome; vasculitis; detection of air leak or pneumothorax; salivary gland dysfunction; painful legs and moving toes syndrome; carotid stenosis; prosthetic graft infection; and scanning of the internal carotid artery during temporary balloon occlusion.
    • Initial or differential diagnosis of suspected dementia, including Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, and vascular dementia; pervasive developmental disorders; and pre-surgical evaluation for lung volume reduction surgery.
    • Colorectal carcinoma imaging, including use with monoclonal antibody or IMMU-4 and CEAScan®; prostate carcinoma imaging, including ProstaScint® with or without CT or MRI fusion; scintimammography for breast cancer; and malignancies other than those listed as medically necessary, including lung and ovarian cancers and differentiation of malignant and benign lung lesions.
    • Any SPECT-CT fusion other than parathyroid imaging; SPECT/ultrasonography fusion imaging in persons with thyroid disease; pre-surgical workup for non-cardiac surgery; surgical planning for axial neck and back pain from disc degeneration (spondylolysis); and other listed non-cardiac uses.
    Denial Risk

    Cerebrovascular Indications Not Medically Necessary

    SPECT scans are not medically necessary for the evaluation or management of cerebrovascular accident (CVA or stroke), subarachnoid hemorrhage, or transient ischemic attack.

    • Cerebrovascular accident (CVA or stroke)
    • Subarachnoid hemorrhage
    • Transient ischemic attack (TIA)
    Denial Risk

    Cardiac Exclusion Criteria

    SPECT is considered experimental and investigational and not medically necessary for cardiac indications considered inappropriate under American College of Cardiology (ACC) appropriateness criteria.

    • Routine screening after PTCA with or without stenting or CABG before discharge from acute care.
    • Routine screening less than 2 years after revascularization when symptoms have not worsened, the member had symptoms before intervention, and there is no history of congestive heart failure.
    • Assessment of vulnerable plaque; evaluation during an acute coronary event with hemodynamic instability, shock, or mechanical complications; and evaluation in acute chest pain or equivalent symptoms with a high likelihood of acute coronary syndrome, acute myocardial infarction, immediate post-thrombolytic status, or marked ST-segment elevation indicating a high pre-test likelihood of significant coronary disease.
    • Before high-risk surgery when asymptomatic and a normal catheterization, coronary intervention, CABG, or nuclear stress test occurred less than 1 year before surgery; before intermediate-risk non-cardiac surgery when standard stress testing is feasible and not contraindicated; and before low-risk non-cardiac surgery for risk assessment.
    • Re-evaluation without chest pain or equivalent symptoms, without known coronary disease, after an initial negative radionuclear study when less than 2 years have elapsed and the member is at high coronary risk based on a Framingham score greater than 10.
    • Re-evaluation without chest pain or equivalent symptoms, or with stable symptoms, in known coronary disease after an abnormal catheterization or SPECT study without prior infarction when less than 1 year has elapsed since the last radionuclear study. More frequent imaging or other testing may be medically necessary with worsening symptoms or silent ischemia.
    • Screening for chest pain or equivalent symptoms when coronary disease probability is low (Framingham score less than 10), there is no diabetes, and non-nuclear stress testing is not impeded or contraindicated; and screening without chest pain or equivalent symptoms when coronary disease probability is low and there is no diabetes.
    Denial Risk

    Myocardial Sympathetic Innervation Imaging

    Myocardial sympathetic innervation imaging, with or without SPECT, is considered experimental and investigational because its effectiveness has not been established.

    • Requests for myocardial sympathetic innervation imaging are not medically necessary under this guideline.
    Denial Risk

    Criteria Not Met: Escalation and Denial Review

    Requests that do not meet the criteria established by this procedure are referred to a TCHP Medical Director or Physician Reviewer for review, and the Denial Policy is followed.

    • Do not represent a request as approved unless authorization has been granted through the applicable review process.
    • Requests that fail to meet medical-necessity criteria may proceed to Medical Director or Physician Reviewer review and denial-policy processing.
    Risk of cardiac death or myocardial infarction less than 1%

    Specified non-cardiac conditions

    SPECT is covered for any of the following specified non-cardiac conditions when the indicated technique is used:

    Covered non-cardiac indications: Brain tumor characterization; liver hemangioma characterization with labeled red blood cells; localization of abscess, infection, inflammation, or fever of unknown origin; selected neuroendocrine tumors with OctreoScan or I-131 MIBG; parathyroid imaging with laboratory evidence or structural suspicion, including SPECT-CT fusion; renal DMSA assessment of scarring and function; pulmonary embolism with ventilation/perfusion scintigraphy; distinguishing Parkinson disease from essential tremor; distinguishing tumor from necrosis in lymphoma; presurgical ictal seizure-focus localization in epilepsy in place of PET; or differentiation of infectious, neoplastic, avascular, or traumatic bone and joint processes, including spondylolysis and stress fractures not visible on x-ray.
    Heart failure conditionThe member must have no history of congestive heart failure
    Cardiac SPECT repeat or reevaluation exclusions
    Less than 1 yearRepeat or reevaluation imaging is excluded for stable or asymptomatic members with known coronary disease based on prior abnormal catheterization or SPECT, without prior infarction, when less than 1 year has elapsed since the last radionuclear study
    Less than 2 yearsReevaluation is excluded for asymptomatic high-risk members after an initial negative radionuclear imaging study when less than 2 years have elapsed
    Low-probability screeningScreening is excluded when the Framingham score is less than 10, there is no history of diabetes, and there are no impediments or contraindications to non-nuclear stress testing