Cardiac Imaging Guidelines

This policy covers cardiac imaging procedures — including echocardiography, nuclear cardiac imaging, cardiac CT/CTA/CAC, cardiac MRI, cardiac PET, diagnostic heart catheterization, pulmonary artery/vein imaging and stress testing — for evaluation of symptoms and conditions such as congestive heart failure, cardiac trauma, adult congenital heart disease, cancer therapeutics‑related cardiac dysfunction, Fabry disease, assessment of hibernating myocardium, and pre‑surgical cardiac testing. Major limitations/requirements include use of the eviCore Clinical Decision Support tool and Pre‑Test Probability Grid for approval, expectation of optimized medical therapy where tolerated, that advanced imaging must address a management‑changing clinical question with a current clinical evaluation and recent ECG (within 60 days), exercise stress achieving a double product >25,000 for adequacy, and physician review for atypical or unaddressed presentations.

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