Cardiac Applications of Positron Emission Tomography Scanning

This policy covers cardiac positron emission tomography (PET) imaging — including myocardial perfusion imaging, myocardial viability assessment (including evaluation of revascularization candidacy), measurement of myocardial blood flow/MFR, and PET for suspected cardiac sarcoidosis (when MRI is contraindicated) — for diagnosis and risk stratification of coronary artery disease and left ventricular dysfunction. Coverage is limited to patients with at least intermediate pretest probability of CAD or when prior noninvasive testing is indeterminate or SPECT is expected to be suboptimal (e.g., severe obesity, large breasts/implants, prior mastectomy); use of FDA‑cleared PET systems and FDA‑approved radiopharmaceuticals is required, off‑label uses are not supported, and benefits are subject to the member’s plan and state regulations.

"Myocardial perfusion imaging using positron emission tomography (PET)"