L28934-LCD

Automated World Health

Local Coverage Determination (LCD) for Myocardial Perfusion Imaging (L28934)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28934

LCD Title Myocardial Perfusion Imaging

Contractor's Determination Number A78451

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 04/15/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

CMS Manual System, Pub. 100-4, Medicare Claims Processing Manual, Chapter 4, Section 30.7.6 and Chapter 13, Section 140-140.3

Program Memorandum Transmittal AB-02-112 (Change Request 2282), dated July 31, 2002.

Indications and Limitations of Coverage and/or Medical Necessity

Myocardial perfusion imaging is a cardiac radionuclide imaging procedure that is usually performed with exercise electrocardiogram ECG/EKG testing for detecting coronary artery disease and determining prognosis. The SPECT (single-photon emission computed tomographic) technique is utilized to obtain multiple-angle images.

Myocardial perfusion imaging will be considered medically reasonable and necessary by Medicare if any one of the following circumstances is present:

• The patient has chest pain, other symptoms, or signs suggestive of coronary artery disease, and the patient has an abnormal baseline EKG (RBBB, LBBB, IVCD, LVH, Atrial fibrillation, marked resting ST segment changes)

which would make interpretation of a standard exercise test inaccurate.

• The patient has chest pain, other symptoms, or signs suggestive of coronary artery disease, and the patient is on a cardiac glycoside (Digoxin) or other medication which would impair the accuracy of interpretation of a standard exercise test.

• The patient has an abnormal or non-diagnostic standard exercise test and myocardial perfusion imaging is being performed in order to determine if the patient has myocardial ischemia.

• The patient has a condition, such as mitral valve prolapse, which would likely result in a non-diagnostic or inaccurate standard stress test.

• Patient has known coronary artery disease (or recent myocardial infarction) and myocardial perfusion imaging is being done to determine the significance of/or the extent of myocardial ischemia (or scar) resulting from coronary artery disease or to assess myocardial viability.

• The patient has undergone cardiovascular re-perfusion (CABG, PTCA, thrombolysis) and perfusion imaging is being done to evaluate the effectiveness of the intervention.

• The patient has developed congestive heart failure and a silent MI is suspected.

• The patient has a ventricular wall motion abnormality demonstrated by another imaging modality and perfusion imaging is needed to further evaluate the abnormality.

• The patient has severe peripheral vascular disease and is a candidate for peripheral vascular reperfusion by balloon angioplasty or bypass surgery and myocardial perfusion imaging is being done pre-operatively because of concern about possible significant coronary artery disease.

• Follow-up within 48 hours of an abnormal multiple myocardial perfusion scan to determine whether the perfusion defect is related to myocardial scarring or myocardial ischemia. Usually only a single study is needed to evaluate this indication.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)

013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

071x Clinic - Rural Health

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

034X Nuclear Medicine - General Classification

CPT/HCPCS Codes

Electromyography

95860 NEEDLE ELECTROMYOGRAPHY; 1 EXTREMITY WITH OR WITHOUT RELATED PARASPINAL AREAS

95861 NEEDLE ELECTROMYOGRAPHY; 2 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95863 NEEDLE ELECTROMYOGRAPHY; 3 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95864 NEEDLE ELECTROMYOGRAPHY; 4 EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS

95867 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL

95868 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL

95869 NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12)

95870 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN 1 EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVESUPPLIED MUSCLES, OR SPHINCTERS

95872 NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED

95885 NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; LIMITED

(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95886

NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN

PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; COMPLETE,

FIVE OR MORE MUSCLES STUDIED, INNERVATED BY THREE OR MORE NERVES OR FOUR OR MORE

SPINAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

95887

NEEDLE ELECTROMYOGRAPHY, NON-EXTREMITY (CRANIAL NERVE SUPPLIED OR AXIAL) MUSCLE(S) DONE

WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE)

Nerve Conduction Studies

95900 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITHOUT FWAVE

STUDY

95903 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITH F-WAVE

STUDY

95904 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY

95905

MOTOR AND/OR SENSORY NERVE CONDUCTION, USING PRECONFIGURED ELECTRODE ARRAY(S),

AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH LIMB, INCLUDES F-WAVE STUDY WHEN PERFORMED,

WITH INTERPRETATION AND REPORT

95934 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD GASTROCNEMIUS/SOLEUS MUSCLE

95936 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS

MUSCLE

95937 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY

1 METHOD

ICD-9 Codes that Support Medical Necessity

411.0 - 411.89 POSTMYOCARDIAL INFARCTION SYNDROME - OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

412 OLD MYOCARDIAL INFARCTION

413.0 - 413.9 ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

414.00 - 414.9 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

424.0 MITRAL VALVE DISORDERS

426.2 LEFT BUNDLE BRANCH HEMIBLOCK

426.3 OTHER LEFT BUNDLE BRANCH BLOCK

426.4 RIGHT BUNDLE BRANCH BLOCK 426.50 - 426.54 opens in

new window BUNDLE BRANCH BLOCK UNSPECIFIED - TRIFASCICULAR BLOCK

426.6 OTHER HEART BLOCK

426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION

427.31 ATRIAL FIBRILLATION

428.0 - 428.9 CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

440.4 CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

794.39* OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM

960.7 POISONING BY ANTINEOPLASTIC ANTIBIOTICS

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.24 FAILED MODERATE SEDATION DURING PROCEDURE

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

E942.0* CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E942.1* CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY

V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V67.59 OTHER FOLLOW-UP EXAMINATION

* According to the ICD-9-CM book, diagnosis codes E942.0 and E942.1 are secondary diagnosis codes and should not be billed as the primary diagnosis.

* ICD-9-CM code V58.69 should be used as a secondary code only and should not be billed as the primary diagnosis.

*ICD-9-CM code 794.39 should be used when an abnormal or non-diagnostic stress test is the reason myocardial perfusion imaging is being performed.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

- Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of myocardial perfusion imaging studies. Also, the results of myocardial perfusion studies must be included in the patient's medical record. This information is normally found in the office/progress notes and/or test results.

- If the provider of myocardial perfusion imaging studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies.

- The medical record must document when significant resting ECG abnormalities are present, or a medication is being used and cannot be withdrawn, that would interfere with the interpretation of a stress ECG, resulting in the selection of a myocardial perfusion study.

- The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the medical record.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Acampa, W., Spinelli, L, Petretta, M, DeLauro, F, Ibello, F. & Cuocolo, A. (2005). Prognostic value of myocardial ischemia in patients with uncomplicated acute myocardial infarction: direct comparison of stress echocardiography and myocardial perfusion imaging [Electronic version]. Journal of Nuclear Medicine, 46:3, 417- 423.

Chevrier, R. (2003). Myocardial perfusion imaging: what patients need to know [Electronic version]. Medscape Radiology, 4:1

Commission on Health Care Policy and Practice Guidelines and Communications Committee (2002). Society of nuclear medicine procedure guideline for myocardial perfusion imaging, version 3.0.

Hacker, M., et al. (2005). Comparison of spiral multidetector CT angiography and myocardial perfusion imaging in the noninvasive detection of functionally relevant coronary artery lesions: first clinical experiences. [Electronic version]. Journal of Nuclear Medicine, 46:8, 1294-1300.

National Guideline Clearinghouse (2005). Procedure guideline for myocardial perfusion imaging. Retrieved November 3, 2005, from www.guideline.gov.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from The Florida Chapter of the American College of Cardiology Society.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 4

Revision History Explanation Revision Number:4 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2011 Revised Effective Date: 04/15/2011

LCR A2011-032

April 2011 Bulletin

Explanation of Revision: Added diagnosis code 794.39 to the list of allowable diagnosis codes. The effective date of this revision is based on date of service.

Revision Number:3

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010 Revised Effective Date: 01/01/2010

LCR A2009-005

December 2009 Bulletin

Explanation of Revision: Annual 2010 HCPCS Update. Added CPT codes 78451, 78452, 78453, and 78454.

Deleted CPT codes 78460, 78461, 78464, 78465, 78478, and 78480. Contractor’s Determination Number was changed from A78460 to A78451. The effective date of this revision is based on date of service.

Corrected effective date for revision #2 to be 12/17/2009 (not 12/10/2009) Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2010 Revised Effective Date: 12/17/2009

LCR A2009-096

December 2009 Bulletin

Explanation of Revision: LCD revised to add ICD-9-CM code V58.69 to the ‘ICD-9 Codes that Support Medical Necessity’ section of the LCD. ICD-9-CM code V58.69 should be used as a secondary code only and should not be billed as the primary diagnosis. The ‘Documentation Requirements’ section of the LCD revised to indicate: The medical record must document when significant resting ECG abnormalities are present, or a medication is being used and cannot be withdrawn, that would interfere with the interpretation of a stress ECG, resulting in the selection of a myocardial perfusion study. The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the medical record. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added new diagnosis code 995.24. The effective date of this revision is based on date of service

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28934) replaces LCD L863 as the policy in notice. This document (L28934) is effective on 02/16/2009.

11/15/2009 - CPT/HCPCS code 78460 was deleted from group 1 11/15/2009 - CPT/HCPCS code 78461 was deleted from group 1 11/15/2009 - CPT/HCPCS code 78464 was deleted from group 1 11/15/2009 - CPT/HCPCS code 78465 was deleted from group 1 11/15/2009 - CPT/HCPCS code 78478 was deleted from group 1 11/15/2009 - CPT/HCPCS code 78480 was deleted from group 1

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 71 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - Revenue code 0343 was added to the code range 0340 - 0349 8/1/2010 - Revenue code 0344 was added to the code range 0340 - 0349

8/1/2010 - The description for Revenue code 0340 was changed 8/1/2010 - The description for Revenue code 0341 was changed

8/1/2010 - The description for Revenue code 0342 was changed 8/1/2010 - The description for Revenue code 0349 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

78451 descriptor was changed in Group 1 78452 descriptor was changed in Group 1 78453 descriptor was changed in Group 1 78454 descriptor was changed in Group 1

Reason for Change