BlueCross BlueShield of Tennessee Medical Policy Manual

Positron Emission Tomography (PET) for Cardiac Applications

DESCRIPTION

Positron emission tomography (PET) images biochemical reactions and physiological functions by measuring concentrations of radioactive chemicals that are partially metabolized in the body region of interest. Radiopharmaceuticals or tracers used for PET are introduced into the body by intravenous injection or by respiration.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Cardiac sarcoidosis is a rare condition in which clusters of white blood cells, called granulomas, form in the tissue of the heart.

SOURCES

American Society of Nuclear Cardiology, Society of Nuclear Medicine & Molecular Imaging. (2016). ASNC & SNMMI joint position statement on the clinical indications for myocardial perfusion PET.  Retrieved Afugust 24, 2021 from www.asnc.org/.

Blankstein, R., Osborne, M., Naya, M., Waller, A., Kim, C.K., Murthy, V.L., et al. (2014). Cardiac positron emission tomography enhances prognostic assessments of patients with suspected cardiac sarcoidosis. Journal of American College of Cardiology, 63 (4), 329-336. (Level 4 evidence)

Einstein, A., Moser, K., Thompson, R., Cerqueira, M. D., & Henzlova, M.J.  (2007). Radiation dose to patients from cardiac diagnostic imaging. Circulation, 116, 1290-1305. (Level 5 evidence)

Youssef, G., Leung, E., Mylonas, I., Nery, P., Williams, K., Wisenberg, G., et al. (2012). The use of F-FDG PET in the diagnosis of cardiac sarcoidosis: a systematic review and meta-analysis including the Ontario experience. Journal of Nuclear Medicine, 53, 241-248. (Level 1 evidence)

ORIGINAL EFFECTIVE DATE:  3/9/2017

MOST RECENT REVIEW DATE:  1/30/2024

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.