Cardiology Non-emergent Outpatient Stress Testing

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for cardiology non-emergent outpatient stress testing. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for cardiology non-emergent outpatient stress testing and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

IOM Citations:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
  • Chapter 6, Sections 20.4 Outpatient Diagnostic Services and 20.4.1 Diagnostic Services Defined
  • Chapter 15, Sections 50 Drugs and Biologicals and 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • Chapter 16, Section 20 Services Not Reasonable and Necessary
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
  • Chapter 1, Part 4, Sections 220.2 Magnetic Resonance Imaging (MRI), 220.5 Ultrasound Diagnostic Procedures, 220.6 Positron Emission Tomography (PET) Scans, 220.6.1 PET for Perfusion of the Heart, 220.6.8 FDG PET for Myocardial Viability, and 220.12 Single Photon Emission Computed Tomography (SPECT)
• CMS IOM Publication 100-04, Medicare Claims Processing Manual,
  • Chapter 13, Sections 40 Magnetic Resonance Imaging (MRI) Procedures, 50 Nuclear Medicine, 60.11 Coverage for PET scans for Perfusion of the Heart Using Ammonia N-13, 60.2.1 Coverage for Myocardial Viability, 60.3.2 Tracer Codes Required for Positron Emission Tomography (PET) Scans, 60.4 PET Scans for Imaging of the Perfusion of the Heart Using Rubidium 82 (Rb 82), and 60.9 Coverage of PET Scans for Myocardial Viability
• CMS IOM Publication 100-08, Medicare Program Integrity Manual,
  • Chapter 13, Section 13.5.4 Reasonable and Necessary Provisions in LCDs

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1861(r)(1) defines “physician” (a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action).
• Title XVIII of the Social Security Act, Section 1861(s)(3) diagnostic tests covered under the Social Security Act and payable under the physician fee schedule have to be performed under the supervision of an individual meeting the definition of a “physician”.
• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Code of Federal Regulations (CFR) References:

• CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• CFR, Title 42, Volume 2, Chapter IV, Part 410.33 Independent diagnostic testing facility.
• CFR, Title 42, Volume 2, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Noninvasive testing in the outpatient setting to assess for coronary artery disease (CAD) and left ventricular (LV) dysfunction may be accomplished by utilizing conventional exercise stress testing without imaging or by utilizing exercise or pharmacologic stress testing with imaging.

Cardiovascular stress testing, also referred to as exercise stress test (EST), exercise electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information about how the heart responds to exertion.

Types of stress testing with imaging addressed in this LCD include stress echocardiography, single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron emission tomography (PET) MPI, and cardiac magnetic resonance imaging (CMR). Stress testing with imaging can be performed with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine, regadenoson, or other provocative agents).^1,2

Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, stress echocardiography can provide information that is not obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction. The most commonly performed myocardial perfusion imaging are single (at rest or stress) and multiple (at rest and stress) SPECT studies. The CMR can also distinguish scar from hibernating myocardium, provide information about valvular function, the presence of myocardial fibrosis, the presence of morphological abnormalities, and provide an assessment of dynamic obstruction without radiation exposure. This is especially valuable in patients in whom good quality echocardiography images could not be obtained due to technically difficult acoustic windows.^3,4

In many instances, EST may be combined with imaging procedures, such as MPI, echocardiography, or other imaging procedures.

A pharmacologic stress test may be performed when patients are unable to exercise. This test involves the administration of a medication that is designed to make the heart respond as if the patient was exercising. The pharmacologic testing allows the provider to determine how the heart responds to stress in the absence of exercise.

Imaging of myocardial perfusion can also be combined with myocardial metabolism imaging with fluorodeoxyglucose (F-18 FDG) for the assessment of myocardial viability in areas of resting hypoperfusion and dysfunctional myocardium. The stress protocols are, for the most part, similar for all cardiac PET perfusion agents. The specific differences in acquisition protocols for rubidium (Rb-82) and ammonia N-13 are related to the duration of uptake and clearance of these radiopharmaceuticals and their physical half-lives.

Covered Indications

Stress testing without cardiac imaging will be considered medically reasonable and necessary for:

1. Patients with low or intermediate pre-test probability for CAD who are exhibiting cardiac symptoms, including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting ECG and no contraindications to exercise.^5-10
2. Patients with diabetes mellitus who are exhibiting cardiac symptoms, including otherwise unexplained angina equivalent symptoms, with normal or minor changes in resting ECG and no contraindications to exercise.¹¹
3. New-onset atrial fibrillation (with no prior cardiac evaluation).^10,12,13
4. Determining functional capacity and response to therapy in patients with hypertrophic cardiomyopathy (HCM).¹⁴
5. Patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope (an abrupt, transient, complete loss of consciousness) and cardiac etiology is suspected based on an initial evaluation, including history, physical examination, or ECG and the patient is able to exercise.^6,8,10,15,16
6. Patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a stent) procedure more than 2 years prior or a coronary artery bypass graft (CABG) more than 5 years prior and have not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography [CCTA], cardiac catheterization) and are able to exercise.^{6,7,8,15,17,18}
7. Patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment elevation myocardial infarction [STEMI], a Non–ST segment elevation myocardial infarction [NSTEMI], or unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time of the acute event and are currently clinically stable and able to exercise.^6,8
8. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress testing evaluation performed within the preceding 2 years and who are able to exercise.^5,7,10,17
9. Pre-operative cardiac evaluation in patients able to exercise and who will be undergoing noncardiac surgery with one of the following¹⁹:
   
   • Intermediate risk for surgery (cardiac risk 1-5%), unknown functional capacity, and the results will affect patient management decisions.
   • High risk for surgery (> 5% cardiac risk), unknown functional capacity, and the results will affect patient management decisions.

Stress testing with cardiac imaging will be considered medically reasonable and necessary for:

1. Patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms, AND any of the following:

• ECG is uninterpretable for ischemia due to any one of the following^{2,5,8,9,15,21}:
  
  
• Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia),²¹
  
  
• Ventricular paced rhythm,
  
  
• Pre-excitation pattern such as Wolff-Parkinson-White,
  
  
• A > 1 mm ST segment depression (NOT nonspecific ST/T wave changes),
  
  
• Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria), or
  
  
• Patient on digoxin therapy.
  
  
• A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or PCI;^6,8,15 OR
  
  
• Syncope and collapse (an abrupt, transient, complete loss of consciousness) for patients with an intermediate or high CHD risk (ATP III risk criteria) and where cardiac etiology is suspected based on an initial evaluation, including history, physical examination, or ECG and patient is unable to exercise;^6,8,10,15,16 OR
  
  
• Evidence or high suspicion of ventricular arrhythmias:^6,7,8,10 OR
  
  
• Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result;^20,22 OR
  
  
• Patients with recent equivocal or borderline testing where ischemia remains a concern;^8,15,20 OR
  
  
• Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study;^2,5 OR
  
  
• History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD);^8,22 OR
  
  
• Evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-test probability for CAD regardless of ECG interpretability or ability to exercise;^7,8 OR
  
  
• High pre-test probability for CAD regardless of ECG interpretability or the ability to exercise, and a decision to perform cardiac catheterization or other angiography has not already been made;^7,8,10,15 OR
  
  
• Patients with HCM;¹⁴ OR
  
  

2. New-onset atrial fibrillation (with no prior cardiac evaluation).^10,12,13
   
   
3. Patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) with no stress imaging evaluation performed within the preceding 2 years and are unable to exercise.^5,7,10,17
   
   
4. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin.^6,8
   
   
5. Patients without cardiac symptoms who underwent a PCI (with stent) procedure more than 2 years prior or a CABG more than 5 years prior and have not undergone an evaluation for CAD within the past 2 years (stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography [CCTA], cardiac catheterization) and are unable to exercise.^{6,7,8,15,17,18}
   
   
6. Patients with established CAD who experienced an ACS event (STEMI, NSTEMI, or unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time of the acute event and are currently clinically stable.^6,8
   
   
7. Evaluating new, recurrent, or worsening left ventricular dysfunction/congestive heart failure.^6-8,10,23
   
   
8. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered.^6-9,15,23
   
   
9. Pre-operative cardiac evaluation in patients not able to exercise and who will be undergoing noncardiac surgery with one of the following^6-8,15,17,19:

• Intermediate risk for surgery (cardiac risk 1-5%), poor (<4 metabolic equivalents [METs]) or unknown functional capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect patient management decisions.
• High risk for surgery (> 5% cardiac risk), poor (<4 METs) or unknown functional capacity, inability to exercise adequately or ECG uninterpretable for ischemia, and the results will affect patient management decisions.

10. Asymptomatic patients with a coronary calcium Agatston score >400.^6-8,17
    
    
11. Planned cardiac or other solid-organ transplant when no cardiac evaluation has been performed within the past year.^10,24
    
    
12. Patients who will be treated with interleukin 2 products for various malignant disorders.²⁵ The Food and Drug Administration (FDA) has issued a black box warning for interleukin 2 products. See the FDA drug label for the FDA black box warning: https://labels.fda.gov/
    
    
13. Stress echocardiography for the evaluation of moderate to severe valvular heart disease, suspected pulmonary artery hypertension, and re-evaluation of exercise-induced pulmonary hypertension to evaluate response to therapy.^6,26
    
    
14. Stress echocardiography for the detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction in the absence of resting LVOT in patients with HCM.¹⁴
    
    
15. CMR in patients with HCM when echocardiography is inconclusive or there are poor echocardiograph imaging windows.⁴
    
    
16. Evaluation of transplant coronary artery disease (TCAD) or cardiac allograft vasculopathy (CAV) in patients with a history of organ transplantation.^27-40
    
    
17. Utilization of PET MPI in the determination of cardiac involvement using fluorodeoxyglucose (F-18 FDG) to diagnose cardiac sarcoidosis in patients who are unable to undergo MRI,have inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. Examples of patients who are unable to undergo MRI include, but are not limited to, patients with metal implants.^15,41-48
    
    
18. Utilization of PET MPI using fluorodeoxyglucose (F-18 FDG) to determine response to immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis.^{15,41-45,47,48}
    
    
19. Additional indications for PET Scans and SPECT are outlined in the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Sections 220.6 Positron Emission Tomography (PET) Scans, 220.6.1 PET for Perfusion of the Heart, 220.6.8 FDG PET for Myocardial Viability, and 220.12 Single Photon Emission Computed Tomography (SPECT).
    
    
20. Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests including echocardiography and nuclear cardiac imaging. However, selection of the test should be made within the context of other testing modalities so that the expected information does not become redundant.
    
    
21. Patients with recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch on an anatomic imaging study (coronary angiogram or CCTA) may have one stress test with imaging.^6-8,49

Limitations

The following are considered not medically reasonable and necessary:

1. Screening for coronary artery disease in asymptomatic patients unless under specific conditions as outlined in this LCD. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20 Services Not Reasonable and Necessary.
   
   
2. Routine screening for CAD in asymptomatic patients with diabetes mellitus.¹¹
   
   
3. Routine stress testing in asymptomatic patients with abnormal prior stress imaging.^6,8,10
   
   
4. Routine stress testing in asymptomatic patients with obstructive or nonobstructive CAD without a revascularization procedure.^6,8,10
   
   
5. Exercise testing or radiologic imaging within the first 2 years following PCI without specific symptoms (e.g., chest pain, ECG changes, etc.).^8,17,18
   
   
6. Utilization of SPECT MPI, PET MPI, stress echocardiography, and CMR in patients with low pretest probability of CAD, interpretable ECG, and the ability to exercise.^6-9,49
   
   
7. The routine and repetitive monitoring of patients beyond the first cardiac stress test, in the absence of a documented change in condition (e.g., new symptoms or progression of existing symptoms).
   
   
8. Cardiovascular stress testing with or without cardiac imaging if the results will not affect patient management decisions.⁴⁹
   
   
9. Cardiovascular stress testing with or without cardiac imaging when a decision to perform cardiac catheterization or other angiography has already been made.⁴⁹
   
   
10. Stress testing with or without imaging for pre-operative evaluation for low risk noncardiac surgery.^6-8,19,49
    
    
11. Stress testing with or without imaging for pre-operative evaluation of asymptomatic patients undergoing intermediate or high risk noncardiac surgery would not be expected for patients 12 months following a normal stress echocardiography, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), or cardiac catheterization.^7,10,19
    
    
12. Utilization of SPECT MPI, PET MPI, stress echocardiography or CMR for the pre-operative evaluation of planned intermediate or high risk, noncardiac surgery, in the patient with normal or minor changes in resting ECG would not be expected for patients with no contraindications to exercise.^6-8,17,19
    
    
13. Absolute contraindications to exercise stress testing (not an all-inclusive list)^2,5:

• Within 2 to 4 days of an acute myocardial infarction
• High-risk unstable angina
• Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
• Symptomatic severe aortic stenosis
• Decompensated or uncontrolled congestive heart failure
• Systolic blood pressure (BP) at rest >200 mmHG or diastolic BP at rest >110 mmHg
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Acute aortic dissection
• Severe pulmonary hypertension
• Acute symptomatic medical illness

14. Please refer to CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCDs), Chapter 1, Part 4, Sections 220.6.8 FDG PET for Myocardial Viability and 220.6.1 PET for Perfusion of the Heart for additional limitations.

Provider Qualifications

Exercise testing must be supervised consistent with the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80. The appropriately trained provider in exercise testing must be capable of recognizing signs and symptoms of cardiac disease and capable of interpreting the exercise test findings. Exercise testing in selected patients may be conducted by a healthcare professional that has training in a related health area, has appropriate training in the supervision of exercise stress tests, and is capable of performing cardio-pulmonary resuscitation.^3,50

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

Multiple guidelines and appropriate use criteria are available for cardiovascular stress testing with and without cardiac imaging.

Pretest probability is used to determine if cardiovascular stress testing is appropriate and whether cardiac imaging is also appropriate.^5-10,15 The pretest probability of CAD is based on age, gender, and symptoms.⁵

Evidence-based guidelines

Exercise stress testing without cardiac imaging

Wolk et al¹⁰ provided the 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. An exercise stress test is recommended for patients exhibiting cardiac symptoms, including otherwise unexplained angina equivalent symptoms with normal or minor changes in resting ECG and no contraindications to exercise.^5-10 Exercise stress testing is also recommended for patients without cardiac symptoms who underwent a percutaneous coronary intervention (PCI) (with a stent) procedure or a coronary artery bypass graft (CABG) more than 2 years prior and have not undergone an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), cardiac catheterization] and are able to exercise.^{6-8,10,15,17,18} Evidence-based guidelines also recommend an exercise stress test for patients with established CAD who experienced an acute coronary syndrome (ACS) event (ST segment elevation myocardial infarction [STEMI], a Non–ST segment elevation myocardial infarction [NSTEMI], or unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time of the acute event and are currently clinically stable and able to exercise.^6,8,10

Evidence-based guidelines


Exercise stress testing without cardiac imaging for patients who can exercise and stress testing with cardiac imaging for patients who are unable to exercise

Multiple articles address that the confounders of stress ECG interpretation include resting ST-segment depression, left ventricular hypertrophy with repolarization abnormalities, left bundle branch block, various medications, pre-excitation pattern such as Wolff-Parkinson-White, and ventricular paced rhythm.^{2,5,8,9,15,21} An exercise or pharmacological imaging study should be considered for patients with an abnormal resting ECG due to left bundle branch block, pre-excitation syndrome, left ventricular hypertrophy (LVH), new-onset atrial fibrillation, or digoxin therapy, because the accuracy of the exercise ECG in detecting provocable ischemia is reduced.^2,5,10,12,13 An exercise or pharmacological imaging study should also be considered for patients with disease conditions associated with CAD (e.g., atherosclerotic abdominal aortic aneurysm, peripheral vascular disease, carotid artery disease, chronic renal failure) with no evaluation performed within the preceding 2 years.^5,7,10,17

Shen et al¹⁶ provided the 2017 American College of Cardiology/American Heart Association guideline for the evaluation and management of patients with syncope. Stress testing is recommended for patients with an intermediate or high CHD risk (ATP III risk criteria) who have experienced syncope (an abrupt, transient, complete loss of consciousness) when cardiac etiology is suspected based on an initial evaluation, including history, physical examination, or ECG. An exercise stress test is recommended for patients who can exercise and pharmacological stress imaging is recommended for patients who are unable to exercise.^6,8,10,15,16

The guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery states perioperative cardiac and long-term risks are increased in patients who are unable to perform 4 METs of work during daily activities.¹⁹ Perioperative myocardial ischemia and cardiovascular events were more common in those with poor functional status. Patients undergoing low-risk noncardiac surgery and patients undergoing elevated risk noncardiac surgery with moderate or greater functional capacity do not require cardiovascular stress testing. For patients undergoing elevated risk noncardiac surgery with poor (<4 METs) or unknown functional capacity and further testing will impact decision making or perioperative care, it may be reasonable to perform cardiovascular stress testing.

Fleisher et al¹⁹ recommends pre-operative cardiac evaluation in patients undergoing noncardiac surgery with an intermediate risk for surgery (cardiac risk 1-5%) or with a high risk for surgery (> 5% cardiac risk) and the results will affect patient management decisions. In this regard, exercise stress testing is recommended for patients who are able to exercise and pharmacologic stress testing for patients who are unable to exercise.

Stress testing with cardiac imaging

Pharmacological imaging studies may be appropriate for those patients who are unable to reach 75–100 percent of their age-predicted maximum heart rate by physiologic exercise.

The SPECT MPI is highly accurate to diagnose flow-limiting CAD and to stratify risk of ischemic heart disease events.⁹ A strength of SPECT is the availability of robust software programs for the interpretation of MPI. Hendel et al¹⁷ provided a multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria. Dorbala et al²⁴ has also provided SPECT MPI guidelines. Consistent with these guidelines, stress testing with cardiac imaging is recommended for patients without cardiac symptoms who underwent a PCI (with stent) procedure or a CABG more than 2 years prior and have not undergone an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), cardiac catheterization] and are unable to exercise.^6-8,15,17,18 A stress test with cardiac imaging is also recommended for patients with cardiac symptoms who had a PCI procedure (with stent) or a CABG procedure more than 5 years ago and who have not undergone an evaluation for CAD within the past 2 years [stress echocardiogram, SPECT MPI, PET MPI, CMR, CCTA, cardiac catheterization].^6-8,15,17

Evidence-based guidelines also recommend stress testing with cardiac imaging for patients experiencing new, recurrent, or worsening cardiac symptoms, including otherwise unexplained angina equivalent symptoms, and any of the following: a) Physical inability to perform a maximum exercise workload,^{2,5,6,8-10,15,20} b) New or previously unrecognized uninterpretable ECG,^2,5,6,8-10 c) ECG is uninterpretable for ischemia due to any one of the following^{2,5,8,9,15,21}: 1) Complete left bundle branch block (right bundle branch does not render ECG uninterpretable for ischemia); 2) Ventricular paced rhythm; 3) Pre-excitation pattern such as Wolff-Parkinson-White; 4) A > 1 mm ST segment depression (Not nonspecific ST/T wave changes); 5) Left ventricular hypertrophy (LVH) with repolarization abnormalities, also called LVH with strain (Not without repolarization abnormalities or by voltage criteria); or 6) Patient on digoxin therapy. Stress testing with cardiac imaging is also recommended for patients with a history of CAD based on a prior anatomic evaluation of the coronary arteries or a history of CABG or PCI.^6,8,15

Consistent with evidence-based guidelines, stress testing with cardiac imaging is recommended for patients with the following conditions: a) Evidence or high suspicion of ventricular arrhythmias,^6-8,10 b) Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result,^20,22 c) Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study,^2,5 d) History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD),²² e) Evaluation of chest pain syndrome after revascularization or in patients with intermediate to high pre-test probability for CAD regardless of ECG interpretability or ability to exercise,^7,8 and f) High pre-test probability for CAD regardless of ECG interpretability or the ability to exercise, and a decision to perform cardiac catheterization or other angiography has not already been made.^7,8,10,15

Meta-Analysis

Stress testing with cardiac imaging


The Lipinski et al article was a meta-analysis which showed that stress CMR provided excellent prognostic stratification of patients with known or suspected CAD.¹ Patients with a negative stress CMR had a <1% annualized event rate for cardiovascular death or nonfatal myocardial infarction. Patients with a positive stress CMR had a 5% annualized event rate. The presence of late gadolinium enhancement (LGE) during CMR suggested an increased risk for major adverse cardiovascular events. This imaging modality not only provides assessment of ischemia and recognition of LGE but can also identify valvular heart disease and assess cardiac structure and function. Stress CMR is considered to be comparable to other stress testing modalities in patients who cannot exercise. The Leiner et al position paper supports that in addition to assessing for myocardial ischemia, CMR can also distinguish scar from hibernating myocardium, provide information about valvular function, the presence of myocardial fibrosis, the presence of morphological abnormalities, and provide an assessment of dynamic obstruction. This is especially valuable in patients in whom good quality echocardiography images could not be obtained due to technically difficult acoustic windows.^3,4 The 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy indicates that while echocardiography continues to be the foundational imaging modality for patients with HCM, CMR will also be helpful in many patients, especially those in whom there is diagnostic uncertainty, poor echocardiographic imaging windows, or where uncertainty persists regarding decisions around implantable cardioverter-defibrillator (ICD) placement.⁴

The appropriate use criteria for echocardiography is a meta-analysis that addresses appropriate use of echocardiography.⁶ Stress echocardiography is recommended for asymptomatic patients with a coronary calcium Agatston score >400, for patients with new or worsening symptoms with a previous abnormal stress test and the inability to exercise. A stress echocardiography is also recommended for evaluating inducible ischemia in patients with an intermediate risk for coronary artery blockages and have established CAD, experienced an ACS event (STEMI, NSTEMI, or unstable angina) within the past 90 days provided that they did not undergo coronary angiography at the time of the acute event and are currently clinically stable. Additionally, stress echocardiography is recommended to assess chronic valvular disease, pulmonary hypertension, new, recurrent, or worsening left ventricular dysfunction/congestive heart failure, to assess patients without clear cardiac symptoms in the presence of an elevated cardiac troponin, and to evaluate patients with recent equivocal or borderline testing where ischemia remains a concern. Stress echocardiography, as well as myocardial perfusion imaging or cardiac magnetic resonance is also recommended to assess myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered.⁴⁹ In addition, the guideline for the diagnosis and treatment of hypertrophic cardiomyopathy (HCM) addresses the use of stress echocardiography for the detection of dynamic LVOT obstruction.¹⁴

Cardiac involvement in sarcoidosis may lead to adverse outcomes such as advanced heart block, arrhythmias, cardiomyopathy, or death. Multiple articles support F-18 FDG PET MPI is indicated to diagnose cardiac sarcoidosis in patients who are unable to undergo MRI, have inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. The PET MPI is also indicated to determine response to immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis.^15,41-48 The PET MPI can be safely performed on patients with intracardiac devices and advanced renal disease and is considered to be an appropriate tool to predict and assess response under therapy.^{41,44,46,47,51-53}

Multiple articles address the increased risk for premature cardiovascular disease following organ transplantation.^10,27-35 There are unique factors in organ transplant recipients that include underlying comorbidities and metabolic effects of immunosuppression.²⁷ In this regard, the Ducloux et al study demonstrates the cumulative impacts of traditional and nontraditional cardiovascular risk factors in renal transplant recipients.²⁸ Also, according to Gamba et al, cyclosporine, regardless of the blood cyclosporine levels, is the main risk factor for coronary artery disease.²⁹ Additionally, Tepperman et.al noted that although immunosuppressive agents are sufficient to minimize allograft rejection and promote short-term survival after transplantation, a major limitation to longer-term survival is the development of allograft vasculopathy.³⁰ Central to development of allograft vasculopathy is endothelial damage and subsequent dysfunction. The factors contributing to endothelial dysfunction include organ preservation solutions, ischemia and reperfusion injury, acute allograft rejection episodes, dyslipidemia, hypertension, diabetes mellitus, and the use of immunosuppressive drugs. Notably, many of the currently used immunosuppressants cause endothelial dysfunction after transplantation.

The Kazmirczak et al article found that regadenoson stress CMR imaging is safe and well tolerated in heart transplant recipients.³⁶ An abnormal regadenoson stress CMR identifies heart transplant recipients at a higher risk for major adverse cardiovascular events. Also, Kan and Bangalore found that among renal transplant recipients, SPECT-MPI predicted risk of cardiovascular death and cardiovascular hospitalization events.³⁸ The Sade et al article also concluded that echocardiographic coronary flow reserve is very sensitive for detecting cardiac allograft vasculopathy and increases the diagnostic accuracy of dobutamine stress echocardiography in heart transplant recipients.³⁹ Additionally, Elhendy et.al found dobutamine stress myocardial perfusion imaging is a safe and feasible method for evaluation of coronary artery disease in heart transplant recipients.⁴⁰ Evidence-based guidelines¹⁰ also recommend stress imaging prior to planned cardiac or other solid-organ transplant.

Situations in which cardiovascular stress testing is not recommended

Stress testing with or without imaging for pre-operative evaluation of asymptomatic patients undergoing intermediate or high risk noncardiac surgery would not be expected for patients 12 months following a normal stress echocardiography, SPECT MPI, PET MPI, CMR, coronary computed tomography angiography (CCTA), or cardiac catheterization.^7,10,19 Also, utilization of SPECT MPI, PET MPI, stress echocardiography or CMR for the pre-operative evaluation of planned intermediate or high risk, noncardiac surgery, in the patient with normal or minor changes in resting ECG would not be expected for patients with no contraindications to exercise^6-8,17,19

The review of the American Diabetes Association standards of medical care in diabetes 2018 states routine screening for CAD in asymptomatic patients is not recommended as it does not improve outcomes if atherosclerotic cardiovascular disease risk factors are treated. Screening is not recommended in part because high risk patients should already be receiving intensive medical therapy-an approach that provides benefit similar to that of invasive revascularization.¹¹ The review states to consider investigations for CAD in the presence of atypical symptoms, signs and symptoms of associated vascular disease, or electrocardiogram abnormalities.

Absolute and relative contraindications to exercise testing are addressed by Henzlova and Gibbons.^2,5 Although exercise testing is generally a safe procedure, both myocardial infarction and death have been reported at a rate of approximately 1 per 2500 tests. Therefore, it is vital to use good clinical judgement in decisions regarding which patients should undergo exercise testing.

Qaseem et al⁴⁹ discussed the clinical practice guideline for diagnosis of stable ischemic heart disease and indicated pharmacologic stress imaging by MPI, echocardiography, or CMR are not recommended for patients with an interpretable ECG and who are able to exercise. Cardiovascular stress testing with or without cardiac imaging is also not recommended when a decision to perform cardiac catheterization or other angiography has already been made or for pre-operative evaluation for low risk noncardiac surgery. Also, only one type of stress test should be performed in patients who recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch on an anatomic imaging study (coronary angiogram or CCTA). Additionally, consistent with evidence-based guidelines, exercise testing or radiologic imaging performed within 2 years of PCI without specific symptoms (e.g., chest pain, ECG changes, etc.) is not recommended.^8,17,18

Cardiac stress tests play an important role in the diagnosis and management of cardiovascular disease. Pretest probability is used to establish if cardiovascular stress testing or cardiac imaging is appropriate. Multiple guidelines and appropriate use criteria are available for cardiovascular stress testing with and without cardiac imaging. Meta-analyses of literature offer recommendations regarding the suitable use of exercise stress testing and pharmacologic stress testing in the diagnosis and treatment of symptomatic or asymptomatic patients with known or suspected CAD. Pharmacologic imaging studies may be appropriate for those patients who are unable to reach 75–100 percent of their age-predicted maximum heart rate by physiologic exercise. The various guidelines and literature also address absolute and relative contraindications to exercise testing.

Studies have shown that perioperative myocardial ischemia and cardiovascular events were more common in those with poor functional status. Therefore, it may be reasonable to perform cardiovascular stress testing in patients undergoing high risk noncardiac surgery with poor (<4 METs) or unknown functional capacity as this information could possibly impact decision making or perioperative care. However, consistent with evidence-based guidelines, patients who will be undergoing low-risk noncardiac surgery and patients who will be undergoing elevated risk noncardiac surgery with moderate or greater functional capacity do not require cardiovascular stress testing.

The SPECT MPI is highly accurate to diagnose flow-limiting CAD and to stratify risk of ischemic heart disease events. A strength of SPECT is the availability of robust software programs for the interpretation of MPI. Studies have also shown that the SPECT-MPI has successfully predicted risk of cardiovascular death and cardiovascular hospitalization events in renal transplant recipients. Additionally, studies have indicated that dobutamine stress MPI is a safe and feasible method for evaluation of coronary artery disease in heart transplant recipients.

Studies show that patients with a negative stress CMR had a <1% annualized event rate for cardiovascular death or nonfatal myocardial infarction whereas patients with a positive stress CMR had a 5% annualized event rate suggesting that the stress CMR provides an excellent prognostic stratification of patients with known or suspected CAD. The stress CMR not only provides assessment of ischemia and identifies the presence of LGE but can also recognize valvular heart disease and assess cardiac structure and function. Stress CMR also seems to be comparable to other stress testing modalities. Studies have shown that an abnormal regadenoson stress CMR identifies heart transplant recipients at a higher risk for major adverse cardiovascular events. Studies indicate CMR imaging is safe and well tolerated as a prognostic stratification tool for recognizing valvular heart disease, assessing cardiac structure and function and identifying heart transplant recipients at a higher risk for adverse cardiovascular events.

Stress echocardiography is used for patients with known or suspected CAD who are symptomatic or asymptomatic. Stress echocardiography is used to assess chronic valvular disease and pulmonary hypertension and for the detection of LVOT obstruction. Also, studies have found that the echocardiographic coronary flow reserve is very sensitive for detecting cardiac allograft vasculopathy and increases the diagnostic accuracy of dobutamine stress echocardiography in heart transplant recipients.

The F-18 FDG PET MPI is indicated to diagnose cardiac sarcoidosis in patients who are unable to undergo MRI, have inconclusive MRI findings, or when high probability of disease exists even after a negative MRI. The PET MPI is also indicated to determine response to immunosuppressive therapy in patients diagnosed with cardiac sarcoidosis. The PET MPI can be safely performed on patients with intracardiac devices and advanced renal disease and is considered to be an appropriate tool to predict and assess response under therapy.

Stress echocardiography, SPECT MPI, PET MPI and CMR are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, stress echocardiography can provide information that is not obtainable with MPI, such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction.

Please refer to the related Local Coverage Article: Billing and Coding: Cardiology Non-Emergent Outpatient Stress Testing (A56952) for documentation requirements, utilization parameters and all coding information as applicable.

First Coast Service Options, Inc. L36209 Cardiology – non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET

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