23 Miss. Code. R. 220-1.10 - Nuclear Cardiac Imaging Studies

A. Effective July 1, 2013, nuclear cardiac imaging studies must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid covers the following nuclear cardiac imaging:

1. Perfusion of the heart, either at rest or with pharmacological stress, for the diagnosis and management of beneficiaries with known or suspected coronary artery disease when one (1) of the following criteria are met:

a) The PET scan, whether at rest alone or at rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT) scan, or

b) The PET scan, whether at rest alone or at rest with stress, is performed following an inconclusive SPECT scan.

1) The PET scan must be considered medically necessary to determine what medical or surgical intervention is required to treat the beneficiary.

2) The Division of Medicaid defines an inconclusive SPECT scan as a test(s) whose results are equivocal, technically uninterpretable, or discordant with a beneficiary's other clinical data documentation in the beneficiary's medical record.

2. For the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization or following an inconclusive SPECT.

a) A SPECT scan is not covered following an inconclusive PET scan.

b) Refer to Rule 1.10.B.1.b) 2).

C. The Division of Medicaid does not cover a SPECT/CT (Single Photon Emission Computed Tomography) which involves a SPECT multi-planar imaging (MPI) nuclear medicine scan only for:

1) Localization,

2) Accuracy, and

3) Attenuation correction purposes.

Notes

23 Miss. Code. R. 220-1.10

Miss. Code Ann. § 43-13-121; 42 CFR §§431.10(e), 440.230(d).

Added Rule 1.10.C. eff. 01/01/2014.