A9582 — Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that the marketed version of the MIBG test (and any scoring algorithms) was used.
- Description of the reference standard used for comparison must be provided.
- Documentation of patient/sample clinical characteristics.
- Documentation of patient/sample selection criteria.
Key Coverage Criteria
- Use as a prognostic marker in individuals with heart failure to identify those at risk of 1-year mortality
- Use as a prognostic marker in individuals with heart failure to identify those at risk of 2-year mortality
- Use to guide treatment decisions for patients with heart failure
- Use to monitor the effectiveness of heart failure treatments
- Use of Iodine-123 MIBG imaging to assess myocardial sympathetic innervation in individuals with heart failure.
- Detection of primary or metastatic pheochromocytoma or neuroblastoma as an adjunct to other diagnostic tests (FDA-approved indication for AdreView/lobenguane I-123).
6 Active Policies
ANTHEM-RAD.00064 — RAD.00064 Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
BCBSIL-RAD604.012 — Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
BCBSMT-RAD604.012 — Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
BCBSNM-RAD604.012 — Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
Related Codes
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