ModifiedUnitedHealthcarePolicy MMP242.17

Positron Emission Tomography (PET) Scan for Myocardial Imaging

Criteria and coding for use of positron emission tomography (PET) to assess myocardial perfusion and viability; applies to UnitedHealthcare medical policy determinations for myocardial PET imaging.

Policy Summary

PayerUnitedHealthcare

PolicyPositron Emission Tomography (PET) Scan for Myocardial Imaging

Policy CodePolicy MMP242.17

Change TypeUpdated references and CMS document listings

Effective DateMay 1, 2025

Next Review Date

Key ActionFollow UnitedHealthcare prior authorization policies and applicable LCD/NCD guidance for the listed myocardial PET CPT codes.

SourceLink

POLICY UPDATE CHANGES

Updated References sections to reflect the most current information and archived previous policy version MMP242.16.

Added CMS Related Documents listing in the Summary of Changes to reflect current Medicare Coverage Database documents.

10pages

78429-78434,78459,78491-78492Applicable CPT codes

85-95%Sensitivity (meta-analysis)

84-91%Specificity (meta-analysis)

BMI>30

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Myocardial PET

inv-01: Covered Indications and Appropriate Uses

PET myocardial perfusion imaging (MPI) and PET myocardial viability are considered reasonable and/or appropriate in the following clinical contexts:

Acute Myocardial Infarction (AMI): PET MPI is not typically performed during the acute period of myocardial infarction (MI) if the diagnosis is established by other means; PET MPI is appropriate for assessment of disease severity, risk/prognosis, efficacy of acute reperfusion therapy, evidence of myocardial salvage, or suspected infarction when history and other tests are not diagnostic.

[[chunk 4]]

Unstable Angina: PET MPI may be useful as an adjunct when the combination of history and other tests is not diagnostic; appropriate for identifying ischemia distribution, severity/extent in medically unstable or ongoing ischemia, and measurement of left ventricular function.

[[chunk 5]]

Chronic Ischemic Heart Disease/Stable CAD: PET MPI is well established for diagnosis and management of CAD including: diagnosis in atypical chest pain; evaluation of abnormal or suspected false‑positive stress ECG; assessment of symptoms suspicious for CAD (eg, syncope, ventricular arrhythmia); assessment of myocardial viability after revascularization or medical management; planning PTCA; preoperative evaluation before high‑risk surgery; identification of presence/location/extent/severity of ischemia; assessment of drug therapy; evaluation for restenosis after PTCA or ischemia after CABG; and follow‑up of symptomatic ischemic heart disease.

[[chunk 6]]

Congenital Heart Disease (CHD): Echocardiography is the method of choice for CHD evaluation; PET MPI may be used to diagnose anomalies of coronary circulation and Kawasaki disease when indicated.

[[chunk 7]]

Post‑Transplant Cardiac Disease: PET MPI may be used to assess coronary arteriopathy and to evaluate ventricular dysfunction related to post‑transplant rejection.

[[chunk 8]]

Myocardial Viability and Infiltrative Disease (e.g., Cardiac Sarcoidosis): PET myocardial viability with F‑18 FDG is reasonable to determine cardiac involvement in sarcoidosis when MRI is not possible or is inconclusive (including patients with metal implants) and to determine response to immunosuppressive therapy in cardiac sarcoidosis.

[[chunk 9]]

Combination Perfusion/Viability Imaging: Combined perfusion and metabolic imaging (eg, dual radiotracer PET with perfusion agent plus F‑18 FDG) may be used to assess viability in areas of resting hypoperfusion and dysfunctional myocardium; protocol differences relate to radiopharmaceutical half‑lives (Rb‑82, N‑13 ammonia).

[[chunk 10]]

inv-02: COVERAGE CRITERIA

Covered when ALL of the following are met:

Eligibility

Additional indications: One or more of: prior equivocal or inconclusive stress imaging; body characteristics affecting image quality (eg, BMI > 30, large breasts, chest wall deformity); young patients requiring reduced radiation exposure; high‑risk patients (eg, diabetes, chronic kidney disease, suspected high‑risk CAD, suspected transplant vasculopathy); situations where myocardial blood flow quantification is needed

PET myocardial perfusion imaging (MPI) is not typically performed during the acute period of myocardial infarction (MI) when the diagnosis has already been established by other means. PET MPI may be appropriate in the acute setting only for specific clinical purposes such as assessment of disease severity, risk/prognosis, efficacy of reperfusion therapy, evidence of myocardial salvage, or when history and other tests do not provide a diagnostic result.

PET perfusion and myocardial blood flow quantification should be applied selectively to clinical scenarios that will affect diagnosis or management. These techniques should not be used in asymptomatic individuals or applied uncritically to assess coronary microvascular dysfunction; appropriate use requires targeting situations where results will provide meaningful diagnostic or prognostic information.

Benefit coverage for services described in this policy is determined by the member-specific benefit plan document. That document identifies covered, excluded, and limited services and supersedes this policy in the event of a conflict. For questions about an individual member’s coverage, providers should refer to the member’s benefit plan or contact the number on the member ID card.

When PET MPI and Viability Are Covered

inv-28: PET for myocardial perfusion and viability

AMI uses: Assessment of disease severity, prognosis, reperfusion efficacy, myocardial salvage, or when diagnosis not confirmed by other tests.

[[chunk 4]]

Unstable angina uses: Adjunct when other tests are non‑diagnostic; identify ischemia distribution, extent/severity, and measure left ventricular function.

[[chunk 5]]

Chronic ischemic heart disease uses: Diagnosis of CAD, evaluate abnormal or suspected false‑positive stress ECG, preoperative evaluation for high‑risk surgery, viability assessment after revascularization, planning PTCA, post‑PTCA/CABG symptom assessment, and follow‑up of symptomatic ischemic disease.

[[chunk 6]]

CPT Codes and Coding Notes

Positron Emission Tomography Perfusion of the Heart / Myocardial Viability (group 1)CPTCovered

78430	Myocardial imaging, positron emission tomography (PET), perfusion study; single study, at rest or stress, with concurrently acquired CT transmission scan
78431	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress, with concurrently acquired CT transmission scan
78434	Absolute quantitation of myocardial blood flow (AQMBF), PET, rest and pharmacologic stress (List separately in addition to code for primary procedure)
78429	Myocardial imaging, PET, metabolic evaluation study; single study, with concurrently acquired CT transmission scan
78459	Myocardial imaging, PET, metabolic evaluation study; single study
78432	Myocardial imaging, PET, combined perfusion with metabolic evaluation

Positron Emission Tomography Perfusion of the Heart / Myocardial Viability (group 2)CPTCovered

78433	Myocardial imaging, PET, combined perfusion with metabolic evaluation, dual radiotracer; with concurrently acquired CT transmission scan
78491	Myocardial imaging, PET, perfusion study; single study, at rest or stress
78492	Myocardial imaging, PET, perfusion study; multiple studies at rest and stress

Medicare-related CPT codes referencedCPT

78432	Perfusion of the Heart/Myocardial Viability (CPT code listed)
78433	Perfusion of the Heart/Myocardial Viability (CPT code listed)
78491	Perfusion of the Heart/Myocardial Viability (CPT code listed)
78492	Perfusion of the Heart/Myocardial Viability (CPT code listed)

inv-09: Body mass index — example affecting image quality (BMI > 30)

Body mass index thresholdBMI > 30

Role as image-quality factorListed as an example of body characteristics that affect image quality and support selecting rest-stress myocardial perfusion PET

Context for useApplied when patients are unable to complete exercise testing or prior testing was inconclusive and body habitus may degrade other modalities

Provider and Billing Actions

Prior Authorization

Prior Authorization / Plan Rules

Prior authorization for the listed CPT codes may be required per UnitedHealthcare or its delegated entities. Verify prior authorization rules with the member's plan or the plan delegate before scheduling services.

Affected CPT codes: 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492

Billing Rule

Check Medicare NCDs / LCDs

Check applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) — including NCD 220.6.1 and NCD 220.6.8 and the LCDs referenced below — to determine coverage and documentation requirements for PET myocardial perfusion and viability studies.

Key NCDs: NCD 220.6.1 (PET for Perfusion of the Heart); NCD 220.6.8 (FDG PET for Myocardial Viability)

Prior Authorization Requirements

Prior Authorization

Follow UnitedHealthcare prior authorization and LCD/NCD guidance

Follow UnitedHealthcare prior authorization policies and applicable LCD/NCD guidance for the listed myocardial PET CPT codes when requesting authorization or scheduling the study.

Follow UHC prior authorization policies
Cross-check authorizations against applicable LCDs/NCDs

Prior Authorization

Follow member plan or delegate prior authorization rules

Follow member-specific plan or delegate requirements for utilization management and prior authorization; when a delegate manages prior authorization, its rules must be followed.

If a delegate manages prior authorization, follow the delegate's requirements
Verify member-plan requirements prior to service

Note

Definitions and Terms

inv-23: Positron emission tomography (PET)

DefinitionA diagnostic imaging procedure using injected radiopharmaceuticals that emit positrons; a PET camera measures decay to provide biochemical information on tissue metabolism.

Typical radiopharmaceuticalsExamples include Rb-82, N-13 ammonia, and F-18 FDG (document describes radiopharmaceuticals generically).

Primary usesEvaluation of metabolism and myocardial perfusion in normal and diseased tissues (e.g., ischemic heart disease).

inv-24: Myocardial perfusion imaging (MPI) / Myocardial viability

DefinitionPET protocols to assess myocardial blood flow (perfusion) and metabolic activity (viability), including single or combined perfusion/metabolic studies and absolute quantitation of myocardial blood flow.

Combined imaging

Background and Evidence

Positron emission tomography (PET) is a minimally invasive diagnostic imaging procedure in which injected radiopharmaceuticals emit positrons and a PET camera detects their decay to provide biochemical information. In cardiac applications, PET evaluates myocardial perfusion and tissue metabolism using tracers such as rubidium-82, nitrogen-13 ammonia, or fluorine-18 FDG to assess ischemia, viability, and certain inflammatory or infiltrative myocardial conditions.

Policy Revision History

2025-05-01policy_revisionLatest

Updated CMS Related Documents listing and References; archived prior policy version MMP242.16.

Policy Summary

PayerUnitedHealthcare

PolicyPositron Emission Tomography (PET) Scan for Myocardial Imaging

Policy CodePolicy MMP242.17

Change TypeUpdated references and CMS document listings

Effective DateMay 1, 2025

Next Review Date

Key ActionFollow UnitedHealthcare prior authorization policies and applicable LCD/NCD guidance for the listed myocardial PET CPT codes.

SourceLink

On This Page

Congenital heart disease uses: Diagnosis of coronary circulation anomalies and Kawasaki disease when echocardiography is insufficient.

Post‑transplant uses: Assessment of coronary arteriopathy and ventricular dysfunction related to rejection.

[[chunk 8]]

Sarcoidosis/infiltrative disease uses: FDG PET for cardiac involvement when MRI is not feasible or is inconclusive; to assess response to immunosuppressive therapy in cardiac sarcoidosis.

[[chunk 9]]

inv-29: Clinical indications supported by professional guidelines and AUC

Guideline‑supported indications: Rest‑stress myocardial perfusion imaging for suspected or known CAD in patients appropriate for pharmacologic stress or unable to exercise; measurement of myocardial blood flow and coronary flow reserve for multivessel or microvascular disease assessment; myocardial viability assessment; evaluation of cardiac sarcoidosis and myocardial inflammation; evaluation for cardiac device or prosthetic valve infection and LVAD infection; assessment for transplant vasculopathy.

Supported by ACR/ACNM/SNMMI/SPR/STR practice parameters and multi‑society AUC statements.

inv-30: Rest-stress myocardial perfusion PET for suspected/known CAD when stress imaging indicated and listed factors present

Indication for rest‑stress PET

Factors (one or more): Prior stress imaging study was equivocal or inconclusive; body characteristics that affect image quality (eg, BMI > 30, large breasts or breast implants, chest wall deformities); young patients with established CAD who need repeated radiation‑associated imaging; high‑risk patients where diagnostic errors carry greater implications (eg, diabetes, chronic kidney disease, suspected potentially high‑risk CAD, suspected transplant vasculopathy); patients in whom myocardial blood flow quantification is needed to identify multivessel CAD or assess microcirculatory function.
[[chunk 36]]

Representative LCDs: L33457, L38396, L35083, L39521 and others listed in CMS-related documents

Billing Rule

LCD / NCD Compliance Required

Compliance with applicable NCDs, LCDs, and Local Coverage Articles is required where they apply. UnitedHealthcare uses these Medicare determinations to supplement internal criteria; providers must follow Medicare coverage rules for Medicare Advantage members.

When Medicare NCDs/LCDs apply, those determinations govern medical necessity and coverage decisions for Medicare Advantage members
Follow both the Medicare determinations and any additional plan/delegate requirements

Billing Rule

Medicare Documentation & Billing References

Medicare documentation and billing requirements apply. Refer to the cited Medicare NCDs, LCDs, and the CMS Claims Processing Manual Chapter 13 § 60 for PET scan billing, coding, and documentation instructions. Ensure documentation supports medical necessity and coding billed.

Follow CMS Claims Processing Manual Chapter 13 § 60 for PET scan billing and claims processing
Use NCD/LCD billing and coding guidance (A56476, A56952, A56423, A59318, etc.) as referenced

Denial Risk

Denial Risk from Criteria Use

Use of the policy criteria aims to improve consistency but may also increase the risk of inappropriate denials if misapplied. Apply criteria carefully and document clinical rationale when management decisions deviate from guideline language.

Criteria are intended to reduce inappropriate denials but can inappropriately deny care if applied without full clinical context
Document clinical justification when indications fall outside strict criteria to reduce denial risk

Documentation Required

Documentation Retention, Claims Accuracy & Benefit Determination

Providers must retain or have access to supporting documentation and must submit accurate claims consistent with member-specific benefit plan documents and CMS requirements. In case of conflict, the member’s benefit plan document supersedes this policy. For member-specific coverage questions, contact the number on the member ID card or refer to the Administrative Guide.

Retain documentation to support medical necessity when requested
Submit accurate claims using CPT/CMS coding guidelines referenced in this policy
Verify member-specific benefit coverage; plan document supersedes policy if conflict exists

Perfusion imaging can be combined with F-18 FDG metabolic imaging to assess viability in areas of resting hypoperfusion and dysfunctional myocardium.

Protocol considerationsStress protocols are generally similar across perfusion agents; differences relate to radiopharmaceutical half-lives (Rb-82 vs N-13 ammonia).

inv-25: PET MPI — Rest-stress evaluation of ischemia, perfusion, and flow quantification

DefinitionRest-stress myocardial perfusion imaging to evaluate ischemia, perfusion, and allow for flow quantification when indicated.

IndicationsAppropriate for patients with suspected or known CAD who meet criteria for stress imaging and have factors such as prior inconclusive stress imaging or body habitus affecting image quality.

Flow quantificationUsed when myocardial blood flow quantification is needed to identify multivessel or microvascular disease or improve risk stratification.

inv-26: FDG PET/CT — Fluorine-18 FDG PET/CT for infection/inflammation and other indications

DefinitionFluorine-18 fluorodeoxyglucose (F-18 FDG) PET/CT used to assess infection/inflammation (e.g., prosthetic valve endocarditis, LVAD infections) and inflammatory cardiac disease such as sarcoidosis.

Diagnostic performanceMeta-analyses report high specificity and variable sensitivity for infective endocarditis and device-related infections (pooled sensitivities/specificities cited in clinical evidence).

Combination with perfusionFDG PET/CT may be combined with perfusion imaging for myocardial viability assessment when indicated.

inv-27: Myocardial perfusion PET — Rest-stress myocardial perfusion PET

DefinitionRest-stress myocardial perfusion PET used as a first-line preferred test for patients with suspected or known CAD who are unable to complete diagnostic-level exercise stress testing or when pharmacologic stress is indicated.

When preferredPreferred in patients with prior equivocal/inconclusive stress imaging, body habitus affecting image quality, young patients needing reduced radiation exposure, or high-risk comorbidities.

Coding noteRelevant CPT codes for myocardial perfusion PET procedures include codes listed in the policy (e.g., 78430-78434, 78491-78492 where applicable).