Cardiac Imaging Guidelines

Covers specific cardiac imaging modalities (stress imaging, TTE/TEE/stress echo/3D/strain, MPI/MUGA/PET including FDG for infection, CCTA/calcium scoring, cardiac CT/MRI and diagnostic catheterization) for defined clinical scenarios and intervals, and excludes/labels investigational services such as myocardial sympathetic innervation imaging (I‑123 mIBG), myocardial contrast perfusion echo, automated plaque quantification (CPT 0623T–0626T) and certain 3D/automated rendering services. Key requirements for authorization are a documented clinical evaluation within 60 days (relevant H&P, recent ECG/non‑advanced imaging, vitals/BMI), specified prior test results and pretest probability per Table‑1, adherence to modality‑specific indication and repeat‑interval rules, and compliance with coding limitations (e.g., single coronary CTA code per encounter; calcium scoring CPT 75571 not with contrast CTA).

"Evaluate coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels."