Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure

This policy addresses myocardial sympathetic innervation imaging with iodine‑123 MIBG (AdreView/lobenguane I‑123) to assess cardiac sympathetic innervation and serve as a prognostic test in individuals with heart failure. Coverage is focused on patients (notably NYHA class II–III with LVEF ≤35%) using heart‑to‑mediastinum (H/M) ratio (cutoff 1.6) with early and late planar/SPECT imaging while on optimal pharmacotherapy, but many other uses are considered investigational or not covered, FDA approval is limited, and exclusions include recent MI/revascularization/ICD implantation, functioning pacemaker, and severe renal impairment.

"Use as a prognostic marker in individuals with heart failure to identify those at risk of 1-year mortality"

Sign up to see full coverage criteria, indications, and limitations.